Spine Disorders — MCQs

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?

Q15Easy

What are the common causes of vertebra plana?

Q16Easy

CPPD crystals are seen in which disease?

Q17Easy

Which of the following statements about synovial fluid is false?

Q18Medium

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?

Q19Easy

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

Q20Medium

In a case of undifferentiated arthritis, the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies strongly suggests which of the following conditions?

Spine Disorders Indian Medical PG Practice Questions and MCQs

Question 11: What is the early feature of Pott's paraplegia?

A. Flexor spasm
B. Increased tendon jerk
C. Ankle clonus (Correct Answer)
D. Sensory loss

Explanation: **Explanation:** Pott’s paraplegia (spinal cord compression due to Tuberculosis of the spine) typically presents as an **upper motor neuron (UMN) lesion** because the compression occurs at the level of the thoracic or cervical spine. **Why Ankle Clonus is the correct answer:** The earliest clinical signs of spinal cord compression are those of **spasticity** and hyperreflexia. Among these, **ankle clonus** (sustained or unsustained) and an extensor plantar response (Babinski sign) are the earliest objective indicators of pyramidal tract involvement. Before overt motor weakness or sensory loss occurs, the patient often experiences a loss of voluntary control over fine movements and an exaggeration of deep tendon reflexes. **Analysis of Incorrect Options:** * **B. Increased tendon jerk:** While hyperreflexia is an early sign, **clonus** is considered a more sensitive and specific early clinical finding of UMN involvement in the progression of Pott's paraplegia. * **A. Flexor spasm:** This is a **late feature** of paraplegia. It occurs when the spinal cord is severely compressed or completely transected (paraplegia-in-flexion), indicating a loss of inhibitory supraspinal control. * **D. Sensory loss:** Sensory involvement usually occurs **after** motor symptoms in Pott’s disease because the disease typically starts in the vertebral body and compresses the cord anteriorly (affecting motor tracts first). **Clinical Pearls for NEET-PG:** * **Earliest symptom:** Clumsiness or weakness in walking (dragging of toes). * **Earliest sign:** Ankle clonus and extensor plantar response. * **Most common site:** Thoracic spine (narrowest canal, making it most susceptible to compression). * **Types:** Early onset (during active disease) vs. Late onset (years later due to internal gibbus or scarring). * **Prognosis:** Pott's paraplegia has a better prognosis than traumatic paraplegia because the cord is often compressed by "soft" inflammatory material (pus/sequestra) rather than bony transection.

Question 12: Which joint is NOT typically involved in Ankylosing spondylitis?

A. Knee and ankle
B. Sacroiliac joint
C. Wrist and elbow (Correct Answer)
D. Spine

Explanation: **Explanation:** Ankylosing Spondylitis (AS) is a chronic inflammatory seronegative spondyloarthropathy that primarily targets the **axial skeleton** and **large proximal joints**. **Why "Wrist and Elbow" is correct:** AS typically follows a "centripetal" pattern, meaning it involves the spine and large joints close to the trunk. Small distal joints, such as the **wrists, elbows, and small joints of the hands/feet**, are characteristically **spared**. If a patient presents with symmetrical small joint involvement, a diagnosis of Rheumatoid Arthritis is more likely. **Analysis of other options:** * **Sacroiliac (SI) Joint:** Involvement of the SI joint (Sacroiliitis) is the **hallmark** and usually the earliest clinical manifestation of AS. It is mandatory for diagnosis under the Modified New York Criteria. * **Spine:** AS causes progressive ossification of the disc spaces and ligaments (syndesmophytes), leading to the classic "Bamboo Spine" appearance and loss of spinal mobility. * **Knee and Ankle:** While AS is primarily axial, **peripheral arthritis** occurs in approximately 30-50% of cases. When it occurs, it typically affects large, lower-limb joints like the hips, knees, and shoulders. **High-Yield Clinical Pearls for NEET-PG:** * **Genetic Association:** Strongly linked with **HLA-B27** (>90% of cases). * **Key Sign:** "Bamboo Spine" on X-ray due to marginal syndesmophytes. * **Clinical Test:** **Schober’s Test** is used to assess restricted lumbar flexion. * **Enthesitis:** Inflammation at the site of tendon/ligament insertion (e.g., Achilles tendonitis or plantar fasciitis) is a common feature. * **Extra-articular manifestation:** The most common is **Acute Anterior Uveitis**.

Question 13: What is the most common site for prolapse of the intervertebral disc?

A. Cervical region
B. Lower thoracic region
C. Upper thoracic region
D. Lumbar region (Correct Answer)

Explanation: **Explanation:** The **Lumbar region** is the most common site for Intervertebral Disc Prolapse (IVDP) because it bears the maximum weight of the body and undergoes the greatest degree of mechanical stress and mobility. Specifically, the **L4-L5 and L5-S1** levels are the most frequently involved (accounting for over 95% of cases) due to the transition from the mobile lumbar spine to the fixed sacrum and the narrowing of the posterior longitudinal ligament in this area. **Analysis of Options:** * **Cervical region (Option A):** This is the second most common site, typically occurring at C5-C6 or C6-C7. While mobile, it bears significantly less weight than the lumbar spine. * **Lower/Upper Thoracic region (Options B & C):** These are the least common sites for disc prolapse. The thoracic spine is relatively immobile and stabilized by the rib cage (coronal orientation of facet joints), which protects the discs from the rotational and shear forces that cause herniation. **Clinical Pearls for NEET-PG:** 1. **Most common level:** L4-L5 (followed closely by L5-S1). 2. **Nerve Root Rule:** In the lumbar spine, a posterolateral disc protrusion usually compresses the **traversing (lower) nerve root** (e.g., L4-L5 disc affects the L5 root). 3. **Schmorl’s Nodes:** These are vertical prolapses of the nucleus pulposus into the vertebral body, often seen in Scheuermann's disease. 4. **Red Flag:** Cauda Equina Syndrome (saddle anesthesia, bowel/bladder dysfunction) is a surgical emergency associated with massive central lumbar disc herniation.

Question 14: 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?

A. Prolapsed intervertebral disc at L4-L5 level (Correct Answer)
B. Prolapsed intervertebral disc at L5-S1 level
C. Spinal cord astrocytoma
D. Epidural hematoma

Explanation: ### Explanation The clinical presentation is classic for a **Prolapsed Intervertebral Disc (PIVD)** with radiculopathy. The key to identifying the level lies in the neurological deficits: 1. **L4-L5 Level (Option A):** In a posterolateral disc prolapse (the most common type), the **traversing nerve root** is compressed. At the L4-L5 level, the **L5 nerve root** is affected. L5 supplies the **Extensor Hallucis Longus (EHL)** and the **Tibialis Anterior** (partially). Therefore, weakness in **dorsiflexion** and sensory loss (hypesthesia) over the **first web space** (a classic L5 dermatome) confirms L5 involvement. The positive Straight Leg Raise (SLR) test further supports lower lumbar nerve root irritation. 2. **L5-S1 Level (Option B):** This would compress the **S1 nerve root**. Clinical features would include weakness in plantar flexion, loss of the ankle reflex, and sensory loss over the lateral aspect of the foot and little toe. 3. **Spinal Cord Astrocytoma (Option C):** This is an intramedullary tumor. It typically presents with progressive, chronic neurological deficits and upper motor neuron signs. The acute onset following a physical trigger (gardening) and the specific radicular pattern strongly favor a mechanical disc prolapse. 4. **Epidural Hematoma (Option D):** This usually presents with sudden, severe back pain and rapid progression to cauda equina syndrome or paraplegia, often following trauma or in patients on anticoagulants. ### Clinical Pearls for NEET-PG * **Most common site for PIVD:** L4-L5, followed by L5-S1. * **Rule of Thumb:** A posterolateral disc prolapse affects the nerve root *below* the level of the disc (e.g., L4-L5 disc affects L5 root). * **L4 Root:** Weakness in knee extension, loss of knee jerk, sensory loss over the medial malleolus. * **L5 Root:** Weakness in big toe extension (EHL) and foot dorsiflexion, sensory loss over the first web space. * **S1 Root:** Weakness in plantar flexion, loss of ankle jerk, sensory loss over the lateral border of the foot.

Question 15: What are the common causes of vertebra plana?

A. Tuberculosis (TB)
B. Eosinophilic granuloma
C. Metastasis
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Vertebra Plana** (also known as Calvé disease) refers to the uniform collapse of a vertebral body, resulting in a thin, wafer-like or "coin-on-edge" appearance on lateral radiographs, while the adjacent intervertebral discs remain preserved. **Why "All of the above" is correct:** Vertebra plana is a radiological sign rather than a specific diagnosis. It occurs when the vertebral body loses its structural integrity due to infiltration or infection: * **Eosinophilic Granuloma (Langerhans Cell Histiocytosis):** This is the **most common cause** in children. It typically involves a single vertebra (usually thoracic) and often shows remarkable reconstitution of vertebral height after healing. * **Metastasis:** In adults, malignant infiltration (commonly from breast, lung, or prostate) or **Multiple Myeloma** can lead to a complete pathological collapse. * **Tuberculosis (Pott’s Spine):** While TB usually affects the disc space first, it can occasionally cause a complete collapse of the vertebral body, especially in the later stages or in specific "vertebral" types of the disease. **Clinical Pearls for NEET-PG:** 1. **Mnemonic (FETISH):** Common causes include **F**racture (Osteoporotic), **E**osinophilic Granuloma, **T**umor (Metastasis/Myeloma), **I**nfection (TB), **S**teroids (Avascular Necrosis), and **H**emangioma. 2. **Age Factor:** If a child presents with vertebra plana, **Eosinophilic Granuloma** is the top differential. In an elderly patient, think **Malignancy** or **Osteoporosis**. 3. **Disc Space:** A key feature of vertebra plana (especially in EG) is that the **intervertebral disc spaces are preserved**, which helps distinguish it from typical pyogenic discitis.

Question 16: CPPD crystals are seen in which disease?

A. Hypothyroidism
B. Primary hyperthyroidism
C. Hemochromatosis
D. All of the above (Correct Answer)

Explanation: **Explanation:** Calcium Pyrophosphate Deposition (CPPD) disease, often referred to as **Pseudogout**, occurs due to the deposition of calcium pyrophosphate dihydrate crystals in articular cartilage and periarticular tissues. While many cases are idiopathic or age-related, CPPD is strongly associated with specific metabolic and endocrine disorders. **Why "All of the Above" is Correct:** The formation of CPPD crystals is triggered by imbalances in calcium, magnesium, and iron metabolism: * **Hypothyroidism:** Low thyroid hormone levels are associated with decreased clearance of pyrophosphate and are frequently linked with CPPD, though the exact mechanism remains complex. * **Hyperparathyroidism (Primary):** Elevated Parathyroid Hormone (PTH) leads to hypercalcemia. High levels of extracellular calcium promote the precipitation of calcium pyrophosphate crystals. * **Hemochromatosis:** Iron overload inhibits the enzyme **pyrophosphatase**, which normally breaks down pyrophosphate. This leads to an accumulation of pyrophosphate, which then binds with calcium. **High-Yield Clinical Pearls for NEET-PG:** 1. **Radiological Hallmark:** The presence of **Chondrocalcinosis** (linear calcification of articular cartilage), most commonly seen in the **Knee (meniscus)**, wrist (triangular fibrocartilage), and symphysis pubis. 2. **The "4 H's" Association:** Remember the mnemonic for CPPD associations: **H**yperparathyroidism, **H**emochromatosis, **H**ypomagnesemia, and **H**ypothyroidism. 3. **Crystal Morphology:** Under polarized microscopy, CPPD crystals are **rhomboid-shaped** and show **weak positive birefringence** (unlike Gout, which shows needle-shaped, strong negative birefringence). 4. **Spine Involvement:** In the spine, CPPD can cause "Crowned Dens Syndrome," presenting as acute neck pain and fever, mimicking meningitis or discitis.

Question 17: Which of the following statements about synovial fluid is false?

A. Secreted primarily by type A synovial cells (Correct Answer)
B. Follows Non-Newtonian fluid kinetics
C. Contains hyaluronic acid
D. Viscosity is variable

Explanation: ### Explanation The synovial membrane consists of two distinct types of synoviocytes, and understanding their specific functions is crucial for NEET-PG. **1. Why Option A is False (The Correct Answer):** Synovial fluid is primarily a **dialysate of plasma** supplemented with **Hyaluronic acid**, which is secreted by **Type B synoviocytes** (fibroblast-like cells). **Type A synoviocytes** are macrophage-like cells primarily responsible for phagocytosis and removing debris from the joint space. Therefore, stating that Type A cells secrete the fluid is incorrect. **2. Analysis of Other Options:** * **Option B (Non-Newtonian fluid kinetics):** This is true. Synovial fluid does not have a constant viscosity. Its flow properties change under pressure; it becomes less viscous as the shear rate increases (thinning during rapid joint movement), which is a hallmark of non-Newtonian fluids. * **Option C (Contains Hyaluronic acid):** This is true. Hyaluronic acid (hyaluronan) provides the fluid with its characteristic viscosity and serves as a primary lubricant for the articular cartilage. * **Option D (Viscosity is variable):** This is true. Viscosity varies based on the concentration of hyaluronic acid and the rate of joint movement (shear rate). In inflammatory conditions like Rheumatoid Arthritis, viscosity decreases significantly. **Clinical Pearls for NEET-PG:** * **Type A cells:** Phagocytic (Think **A** for **A**ating/Phagocytosis). * **Type B cells:** Secretory (Think **B** for **B**uilding/Secretory). * **Normal Synovial Fluid:** Clear, straw-colored, high viscosity, and forms a long "string" (String test) when dropped from a syringe. * **Rice Bodies:** Small, white free-floating bodies seen in synovial fluid, classically associated with **Rheumatoid Arthritis** and Tuberculosis.

Question 18: 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?

A. Ewing's sarcoma
B. Tuberculosis
C. Histiocytosis (Correct Answer)
D. Metastasis

Explanation: **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.

Question 19: In Klippel-Feil syndrome, the patient has all of the following clinical features except?

A. Low hairline
B. Bilateral neck webbing
C. Bilateral shortness of sternocleidomastoid muscles (Correct Answer)
D. Gross limitations of neck movements

Explanation: **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.

Question 20: In a case of undifferentiated arthritis, the presence of anti-cyclic citrullinated peptide (anti-CCP) antibodies strongly suggests which of the following conditions?

A. Rheumatoid arthritis (Correct Answer)
B. Systemic lupus erythematosus
C. Mixed connective tissue disorder
D. Reactive arthritis

Explanation: ### Explanation **Correct Answer: A. Rheumatoid Arthritis** The presence of **Anti-Cyclic Citrullinated Peptide (anti-CCP)** antibodies is highly specific for **Rheumatoid Arthritis (RA)**. While Rheumatoid Factor (RF) is a sensitive screening tool, it lacks specificity as it can be found in various infections and other connective tissue diseases. In contrast, anti-CCP has a **specificity of >95%**, making it the most reliable serological marker for diagnosing RA, especially in the early "undifferentiated" stages. It is also a significant prognostic marker, predicting more aggressive joint destruction and erosive disease. **Analysis of Incorrect Options:** * **B. Systemic Lupus Erythematosus (SLE):** The hallmark antibodies for SLE are **Anti-dsDNA** (highly specific) and **Anti-Smith** antibodies. While SLE patients may have joint pain, anti-CCP is rarely positive. * **C. Mixed Connective Tissue Disorder (MCTD):** This condition is characterized by features overlapping with SLE, scleroderma, and polymyositis. The definitive serological marker is high titers of **Anti-U1 RNP** antibodies. * **D. Reactive Arthritis:** This belongs to the **Seronegative Spondyloarthropathies** group. These conditions are typically negative for both RF and anti-CCP but are strongly associated with the **HLA-B27** antigen. **High-Yield Clinical Pearls for NEET-PG:** * **Most Specific Marker for RA:** Anti-CCP (ACPA). * **Most Sensitive Initial Test for RA:** Rheumatoid Factor (RF). * **Prognosis:** Patients who are "double positive" (RF+ and anti-CCP+) have the highest risk of radiological progression. * **ACR/EULAR 2010 Criteria:** Serology (RF and anti-CCP) is a core component of the current diagnostic criteria for RA.

Practice by Chapter

Cervical Spine Disorders

Practice Questions

Thoracic Spine Disorders

Practice Questions

Lumbar Spine Disorders

Practice Questions

Intervertebral Disc Disease

Practice Questions

Spinal Stenosis

Practice Questions

Spondylolisthesis

Practice Questions

Spinal Deformities

Practice Questions

Spinal Infections

Practice Questions

Spinal Tumors

Practice Questions

Spinal Cord Injuries

Practice Questions

Minimally Invasive Spine Surgery

Practice Questions

Rehabilitation of Spine Conditions

Practice Questions

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