Spine Disorders Practice Questions

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: Which of the following conditions is treated with the Middle path regimen?

Tuberculosis of the spine. The **Middle Path Regimen** is a classic management protocol specifically designed for **Tuberculosis of the Spine (Pott’s Disease)**. It was popularized by **Professor S.M. Tuli**. ### **Explanation of the Correct Option** **A. Tuberculosis of the Spine:** The "Middle Path" refers to a balanced approach between purely conservative treatment (bed rest and drugs) and universal surgical intervention. It advocates for **multidrug antitubercular therapy (ATT)** as the primary treatment for all patients, reserving surgery only for specific indications such as: * Lack of clinical improvement after 3–6 months of ATT. * Development or progression of neurological deficits (Pott’s paraplegia) despite treatment. * Instability of the spine or severe kyphotic deformity. * Doubtful diagnosis requiring biopsy. ### **Explanation of Incorrect Options** * **B & C (TB Hip and Knee):** While these involve osteoarticular tuberculosis, the specific "Middle Path" terminology and the structured criteria for surgical transition are unique to spinal involvement due to the risk of paraplegia. * **D (Tuberculous Meningitis):** This is a medical emergency involving the central nervous system. Treatment focuses on ATT and steroids to reduce intracranial pressure, not the surgical-conservative balance defined by Tuli’s regimen. ### **High-Yield Clinical Pearls for NEET-PG** * **Most common site of Spinal TB:** Thoracic spine (followed by Lumbar). * **Earliest sign on X-ray:** Reduction in disc space (due to destruction of the subchondral bone). * **Cold Abscess:** A hallmark of TB spine; it lacks the classic signs of inflammation (heat, redness). * **Pott’s Paraplegia:** The most serious complication; the Middle Path Regimen is crucial in deciding the timing of **anterolateral decompression**.

Q: A 65-year-old man with osteoarthritis complains of back pain, worse on walking, along with aching and heaviness in both legs that forces him to stop walking. Pain is relieved slowly after rest or leaning forward. What is the most probable diagnosis?

Spinal stenosis. ### Explanation The clinical presentation describes **Neurogenic Claudication**, the hallmark symptom of **Spinal Stenosis**. **1. Why Spinal Stenosis is Correct:** Lumbar spinal stenosis is most commonly caused by degenerative changes (osteoarthritis) leading to hypertrophy of the *ligamentum flavum*, facet joint arthropathy, and disc bulging. This narrows the spinal canal. * **The Mechanism:** Walking induces lumbar extension, which further narrows the canal and compresses nerve roots/microvasculature. * **Relieving Factors:** Leaning forward (flexion) or sitting increases the canal volume and stretches the ligamentum flavum, providing relief. This is known as the **"Shopping Cart Sign."** **2. Why Other Options are Incorrect:** * **Ankylosing Spondylitis:** Typically affects younger males (<40 years). It presents with morning stiffness that *improves* with activity, not worsens. * **Myeloma:** Presents with "bone pain at rest" and constitutional symptoms (weight loss, anemia). Pain is usually not posture-dependent. * **Pott’s Disease (Spinal TB):** Usually presents with chronic back pain, constitutional symptoms (fever, night sweats), and often a localized deformity (gibbus). It does not typically present with classic neurogenic claudication. **3. NEET-PG High-Yield Pearls:** * **Neurogenic vs. Vascular Claudication:** In vascular claudication (PVD), pain stops immediately upon standing still; in neurogenic claudication, the patient must sit or flex the spine, and relief is slower. * **Investigation of Choice:** MRI is the gold standard for diagnosing spinal stenosis. * **Management:** Initial treatment is conservative (NSAIDs, PT). Surgery (Decompression/Laminectomy) is indicated if neurological deficits progress or quality of life is severely impacted.

Q: All of the following are true about TB Spine except?

All cases are managed surgically. **Explanation:** Tuberculosis of the spine (Pott’s disease) is primarily a medical condition. The correct answer is **D** because the mainstay of treatment is **Antitubercular Therapy (ATT)** for 9–12 months. Surgery is reserved for specific complications such as progressive neurological deficits, spinal instability, or failure of medical management. **Analysis of Options:** * **A. Anterior disease:** TB spine typically starts in the anterior part of the vertebral body (paradiscal type is most common). The infection spreads under the anterior longitudinal ligament, leading to vertebral destruction and the characteristic kyphotic deformity (Gibbus). * **B. Most common location is dorsolumbar:** The transition zone (T12-L1) is the most frequently affected site due to its high mobility and vascularity. * **C. Earliest symptom is pain:** Pain is the most common presenting symptom, often localized and associated with muscle spasms and restricted spinal movements. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Paradiscal (affects adjacent vertebrae and the intervening disc). * **Cold Abscess:** A hallmark of TB spine; it lacks the classic signs of inflammation (heat/redness). Common sites include the psoas sheath (Psoas abscess). * **Radiology:** The earliest sign on X-ray is blurring of the endplates and reduction of disc space. MRI is the investigation of choice. * **Deformity:** Kyphosis (Gibbus) is common. If the angle is >60°, surgical correction is often indicated. * **Pott’s Paraplegia:** Most commonly occurs in the thoracic spine due to the narrow canal diameter.

Q: What is the most common cause of vertebral collapse?

All of the above. **Explanation:** Vertebral collapse, or vertebral compression fracture (VCF), occurs when the structural integrity of the vertebral body is compromised, leading to a loss of height. In clinical practice, the etiology is multifactorial, making **"All of the above"** the correct answer. 1. **Trauma (Option A):** High-energy trauma (e.g., falls from height, motor vehicle accidents) is a leading cause of acute vertebral collapse, particularly at the thoracolumbar junction (T12-L1). In elderly patients with osteoporosis, even trivial trauma can result in a collapse. 2. **Tuberculosis (Option B):** In developing countries like India, **Pott’s spine** (Tuberculous spondylitis) is a very common cause of pathological collapse. The infection typically destroys the anterior part of the vertebral body and the intervening disc, leading to the characteristic **wedging and kyphotic deformity (Gibbus).** 3. **Metastasis (Option C):** Malignancy is the most common cause of **pathological** vertebral collapse in the elderly. Secondary deposits from the breast, lung, prostate, and kidney frequently involve the pedicles and vertebral bodies, leading to structural failure. **Why "All of the above" is correct:** While osteoporosis is statistically the most frequent cause of vertebral collapse globally, Trauma, TB, and Metastasis represent the three most significant clinical categories encountered in surgical practice and exams. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of TB Spine:** Lower Thoracic and Upper Lumbar vertebrae. * **Winking Owl Sign:** An early radiological sign of spinal metastasis (destruction of the pedicle). * **Disc Space Sparing:** Metastasis typically spares the intervertebral disc, whereas TB destroys it. * **Most common level for Traumatic VCF:** T12-L1 (the transition zone).

Q: A child presents with fever, disabling arthritis, rash, and blindness. What is the MOST likely diagnosis?

Juvenile rheumatoid arthritis. ### Explanation The correct diagnosis is **Juvenile Rheumatoid Arthritis (JRA)**, specifically the **Systemic-onset JRA (Still’s Disease)** subtype. **Why JRA is the correct answer:** Systemic JRA is characterized by a classic triad of **high-grade spiking fever**, an evanescent **salmon-pink macular rash**, and **arthritis**. The mention of "blindness" in the question refers to **chronic non-granulomatous anterior uveitis (iridocyclitis)**. This is a high-yield association in JRA; if left untreated, it leads to band keratopathy, cataracts, and eventual blindness. Since the inflammation is often asymptomatic ("white eye"), routine slit-lamp examinations are mandatory for these patients. **Why other options are incorrect:** * **Rheumatic Fever:** While it presents with fever and migratory polyarthritis, it typically follows a streptococcal infection. The rash (Erythema Marginatum) is different, and it does not cause uveitis or blindness. * **Lyme Disease:** Characterized by *Erythema Chronicum Migrans* (bullseye rash) and monoarthritis (usually the knee). While it can cause ocular issues, it is not a classic cause of blindness in the pediatric "fever-rash-arthritis" presentation. * **Henoch-Schönlein Purpura (HSP):** This is a small-vessel vasculitis presenting with palpable purpura (usually on buttocks/legs), abdominal pain, and hematuria. It does not cause blindness. **NEET-PG High-Yield Pearls:** * **Uveitis Risk:** Highest in the **Pauciarticular (Oligoarticular)** subtype, especially if **ANA positive**. * **Still’s Disease:** Look for "Salmon-pink" rash and "Koebner phenomenon." * **Drug of Choice:** NSAIDs are first-line; Methotrexate is the most common DMARD used. * **HLA Association:** JRA is frequently associated with **HLA-B27** (especially in males with enthesitis) and **HLA-DR4**.

Q: Compression of which of the following structures results in pseudoclaudication?

Cauda equina. **Explanation:** **Pseudoclaudication** (also known as neurogenic claudication) is the hallmark clinical feature of **Lumbar Canal Stenosis**. It is caused by the compression of the **cauda equina** nerve roots within the narrowed spinal canal. 1. **Why Cauda Equina is correct:** When the spinal canal narrows (due to disc herniation, ligamentum flavum hypertrophy, or facet joint arthropathy), the nerve roots of the cauda equina are compressed. During walking or standing, the lumbar spine extends, further narrowing the canal and increasing venous congestion around the nerve roots. This leads to transient ischemia of the nerves, causing pain, numbness, and weakness in the lower limbs. 2. **Why other options are incorrect:** * **Femoral/Popliteal Artery:** Compression or atherosclerosis of these arteries leads to **Vascular Claudication**. While the symptoms are similar, vascular pain is triggered by the metabolic demand of muscles and is relieved simply by standing still, whereas neurogenic pain usually requires sitting or leaning forward (flexion). * **Femoral Nerve:** Isolated compression of the femoral nerve typically causes weakness in knee extension and sensory loss over the anterior thigh, but it does not present as a claudication syndrome. **NEET-PG High-Yield Pearls:** * **Shopping Cart Sign:** Patients with pseudoclaudication feel relief when leaning forward (e.g., over a shopping cart) because spinal flexion increases the cross-sectional area of the spinal canal. * **Neurogenic vs. Vascular:** In neurogenic claudication, pulses are present and the pain is "distance-variable," whereas in vascular claudication, pulses are often absent/feeble and the "claudication distance" is fixed. * **Investigation of Choice:** MRI Lumbar Spine is the gold standard for diagnosing canal stenosis.

Q: Which of the following is false about spina bifida occulta?

Early surgical repair is usually indicated.. ### Explanation **Spina Bifida Occulta (SBO)** is the mildest form of neural tube defect, characterized by a failure of the posterior vertebral arches to fuse. **Why Option D is the Correct Answer (False Statement):** Spina bifida occulta is typically an **asymptomatic, incidental finding** discovered on X-rays. In the absence of neurological deficits or associated "tethered cord syndrome," **no surgical treatment is required.** Most cases are benign and do not progress; therefore, "early surgical repair" is incorrect. **Analysis of Other Options:** * **Option A:** This is the definition of the condition. It is a midline defect in the vertebral arches (usually L5 or S1) without protrusion of the spinal cord or meninges. * **Option B:** Unlike *spina bifida cystica* (meningocele/myelomeningocele), the defect in SBO is strictly internal and is always **covered by intact skin**. * **Option C:** While the defect is "occult" (hidden), the overlying skin often provides clues. Cutaneous markers like a **tuft of hair (hypertrichosis)**, a fatty lump (lipoma), a birthmark (hemangioma), or a small dimple/sinus suggest an underlying developmental anomaly of the spinal cord or filum terminale. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Site:** L5 and S1 vertebrae. * **Tethered Cord Syndrome:** If a patient with SBO presents with progressive neurological deficits, bladder dysfunction, or foot deformities (e.g., Pes Cavus), suspect a tethered cord. This is the primary indication for MRI and surgical intervention. * **Screening:** Maternal alpha-fetoprotein (MSAFP) levels are usually **normal** in SBO because the defect is skin-covered (closed NTD). * **Radiology:** Characterized by a "cleft" in the vertebral arch on an AP view X-ray.

Q: Which joint is NOT typically involved in Rheumatoid Arthritis?

Distal interphalangeal joint. Rheumatoid Arthritis (RA) is a chronic, systemic inflammatory disorder characterized by symmetrical polyarthritis that primarily targets the **synovium**. ### **Why the Distal Interphalangeal (DIP) Joint is the Correct Answer** The hallmark of RA is its predilection for small joints with high synovial content. The **DIP joint is characteristically spared** in Rheumatoid Arthritis. If a patient presents with DIP joint involvement, clinicians should instead suspect **Osteoarthritis (Heberden’s nodes)** or **Psoriatic Arthritis**. ### **Analysis of Incorrect Options** * **A. Proximal Interphalangeal (PIP) Joint:** This is one of the most commonly involved joints in early RA, often leading to deformities like the Boutonniere or Swan-neck deformity. * **B. Metacarpophalangeal (MCP) Joint:** Involvement of the MCP joints is a classic feature of RA. Inflammation here leads to the characteristic "ulnar drift" of the fingers. * **D. Cervical C1-C2 Joint:** While RA typically spares the thoracolumbar spine, it frequently involves the cervical spine. Synovitis of the transverse ligament can lead to **atlanto-axial subluxation**, a high-yield surgical emergency. ### **High-Yield Clinical Pearls for NEET-PG** * **Joints Spared in RA:** DIP joints, sacroiliac joints, and the thoracolumbar spine. * **Earliest Radiological Sign:** Periarticular osteopenia (juxta-articular rarefaction). * **Pathognomonic Feature:** Pannus formation (hypertrophied synovium invading cartilage and bone). * **Serology:** Anti-CCP (Cyclic Citrullinated Peptide) is more specific than Rheumatoid Factor (RF). * **Hand Deformities:** Z-deformity of the thumb, Hitchcock’s thumb, and ulnar deviation at MCP joints.

Q: Which joint is typically NOT involved in osteoarthritis?

Metacarpophalangeal joint. **Explanation:** Osteoarthritis (OA) is a degenerative joint disease that primarily affects **weight-bearing joints** and specific small joints of the hand. The **Metacarpophalangeal (MCP) joint** is typically **spared** in primary osteoarthritis. Involvement of the MCP joints is a classic hallmark of inflammatory arthritides, most notably **Rheumatoid Arthritis**. If OA-like changes are seen at the MCP joints, clinicians should investigate secondary causes such as hemochromatosis or trauma. **Analysis of Options:** * **A. Distal Interphalangeal (DIP) joints:** These are the most common sites of hand OA. Bony enlargements here are known as **Heberden’s nodes**. * **B. Knee joint:** This is the most common large weight-bearing joint affected by OA, often leading to genu varum (bow-legs). * **D. Proximal Interphalangeal (PIP) joints:** Frequently involved in hand OA. Bony enlargements here are known as **Bouchard’s nodes**. **High-Yield Clinical Pearls for NEET-PG:** * **Joints Spared in OA:** MCP joints, Wrists, Elbows, and Ankles (unless there is prior trauma). * **Joints Involved in OA:** DIP, PIP, 1st Carpometacarpal (CMC) joint (base of the thumb), Hip, Knee, and Spine (spondylosis). * **Radiological Signs of OA (Mnemonic: LOSS):** **L**oss of joint space (asymmetrical), **O**steophytes, **S**ubchondral sclerosis, and **S**ubchondral cysts. * **Nodal OA:** Strong genetic predisposition, more common in postmenopausal women.

Question 1

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 2

Which of the following conditions is treated with the Middle path regimen?

Accepted Answer

Tuberculosis of the spine

Answer

Tuberculosis of the hip

Answer

Tuberculosis of the knee

Answer

Tuberculous meningitis

Question 3

A 65-year-old man with osteoarthritis complains of back pain, worse on walking, along with aching and heaviness in both legs that forces him to stop walking. Pain is relieved slowly after rest or leaning forward. What is the most probable diagnosis?

Accepted Answer

Spinal stenosis

Answer

Ankylosing spondylitis

Answer

Myeloma

Answer

Pott's disease

Question 4

All of the following are true about TB Spine except?

Accepted Answer

All cases are managed surgically

Answer

Anterior disease

Answer

Most common location is dorsolumbar

Answer

Earliest symptom is pain

Question 5

What is the most common cause of vertebral collapse?

Accepted Answer

All of the above

Answer

Trauma

Answer

Tuberculosis

Answer

Metastasis

Question 6

A child presents with fever, disabling arthritis, rash, and blindness. What is the MOST likely diagnosis?

Accepted Answer

Juvenile rheumatoid arthritis

Answer

Rheumatic fever

Answer

Lyme disease

Answer

Henoch-Schoenlein vasculitis

Question 7

Compression of which of the following structures results in pseudoclaudication?

Accepted Answer

Cauda equina

Answer

Femoral artery

Answer

Femoral nerve

Answer

Popliteal artery

Question 8

Which of the following is false about spina bifida occulta?

Accepted Answer

Early surgical repair is usually indicated.

Answer

It is failure of bony fusion of the vertebral column.

Answer

There is skin covering overlying the vertebral defect.

Answer

Presence of a tuft of hair, lipoma, or sinus on the skin indicates a defect in the spinal cord.

Question 9

Which joint is NOT typically involved in Rheumatoid Arthritis?

Accepted Answer

Distal interphalangeal joint

Answer

Proximal interphalangeal joint

Answer

Metacarpophalangeal joint

Answer

Cervical C1-C2 joint

Question 10

Which joint is typically NOT involved in osteoarthritis?

Accepted Answer

Metacarpophalangeal joint

Answer

Distal interphalangeal joints

Answer

Knee joint

Answer

Proximal interphalangeal joint

Spine Disorders — MCQs

Spine Disorders — MCQs

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