Spine Disorders Practice Questions

Q: Which joint is NOT typically involved in Ankylosing spondylitis?

Wrist and elbow. **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**.

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

Lumbar region. **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.

Q: What are the common causes of vertebra plana?

All of the above. **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.

Q: CPPD crystals are seen in which disease?

All of the above. **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.

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

Secreted primarily by type A synovial cells. ### 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.

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

Rheumatoid arthritis. ### 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.

Question 1

What is the early feature of Pott's paraplegia?

Accepted Answer

Ankle clonus

Answer

Flexor spasm

Answer

Increased tendon jerk

Answer

Sensory loss

Question 2

Which joint is NOT typically involved in Ankylosing spondylitis?

Accepted Answer

Wrist and elbow

Answer

Knee and ankle

Answer

Sacroiliac joint

Answer

Spine

Question 3

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

Accepted Answer

Lumbar region

Answer

Cervical region

Answer

Lower thoracic region

Answer

Upper thoracic region

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

What are the common causes of vertebra plana?

Accepted Answer

All of the above

Answer

Tuberculosis (TB)

Answer

Eosinophilic granuloma

Answer

Metastasis

Question 6

CPPD crystals are seen in which disease?

Accepted Answer

All of the above

Answer

Hypothyroidism

Answer

Primary hyperthyroidism

Answer

Hemochromatosis

Question 7

Which of the following statements about synovial fluid is false?

Accepted Answer

Secreted primarily by type A synovial cells

Answer

Follows Non-Newtonian fluid kinetics

Answer

Contains hyaluronic acid

Answer

Viscosity is variable

Question 8

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 9

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 10

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

Accepted Answer

Rheumatoid arthritis

Answer

Systemic lupus erythematosus

Answer

Mixed connective tissue disorder

Answer

Reactive arthritis

Spine Disorders — MCQs

Spine Disorders — MCQs

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