Spine Disorders — MCQs

An 87-year-old woman presents with lower back pain exacerbated by walking or prolonged standing, and occasionally relieved by bending over. Physical examination reveals a thin elderly woman who walks with a cane, with her lower back moderately flexed. Motor power in her lower extremities is normal, but she has impaired sensation to light touch and vibration below the L4 dermatome bilaterally. Deep tendon reflexes are normal in her upper extremities but absent in both lower extremities. MRI of the lumbosacral spine is performed. What will be the most likely finding on this study?

Q48Medium

A 55-year-old male presents with urinary incontinence and severe back pain for 10 days. Imaging shows a lumbar disc prolapse. He has no history of weight loss or fever. What is the diagnosis?

Q49Easy

What substance is used for vertebroplasty?

Q50Easy

This defect most commonly involves which region of the spine?

Spine Disorders Indian Medical PG Practice Questions and MCQs

Question 41: In which spinal disease are both the bone and disc spaces involved?

A. Tuberculosis (Correct Answer)
B. Osteoporosis
C. Osteoid osteoma
D. Eosinophilic granuloma

Explanation: **Explanation:** In spinal pathology, the involvement of the intervertebral disc is a crucial diagnostic differentiator. **1. Why Tuberculosis (Pott’s Disease) is Correct:** Tuberculosis of the spine typically begins in the paradiscal area of the vertebral body. Because the intervertebral disc is avascular, it derives its nutrition via diffusion from the vertebral endplates. In TB, the infection destroys these endplates, compromising the disc's nutrition and leading to **disc space narrowing**. Furthermore, TB lacks proteolytic enzymes (unlike pyogenic infections), allowing the infection to track under the anterior longitudinal ligament and involve adjacent vertebrae and the intervening disc. **2. Why the other options are Incorrect:** * **B. Osteoporosis:** This is a metabolic bone disease characterized by decreased bone density. While it leads to vertebral "codfish" deformities or wedge fractures, the pathology is confined to the bone; the disc spaces are usually preserved or may even appear "biconvex" due to expansion into the weakened bone. * **C. Osteoid Osteoma:** This is a benign osteoblastic tumor. It typically involves the posterior elements (lamina/pedicle) and causes painful scoliosis. It does not involve the disc space. * **D. Eosinophilic Granuloma:** Part of Langerhans Cell Histiocytosis, this classically causes **Vertebra Plana** (pancake vertebra). Crucially, the disc spaces above and below the collapsed vertebra remain characteristically **normal/preserved**. **Clinical Pearls for NEET-PG:** * **Paradiscal type** is the most common variety of Spinal TB. * **Rule of Thumb:** Infections (TB/Pyogenic) destroy the disc; Tumors (Malignancy/EG) and Metabolic diseases spare the disc. * **MRI** is the investigation of choice for early diagnosis of Spinal TB. * **Cold Abscess:** A hallmark of TB, formed because the inflammatory response lacks the heat and redness of pyogenic infections.

Question 42: A burst fracture is typically caused by which type of mechanism?

A. Vertical compression (Correct Answer)
B. Whiplash injury
C. Wedge compression
D. Avulsion fracture

Explanation: **Explanation:** **1. Why Vertical Compression is Correct:** A **Burst fracture** is a specific type of spinal injury characterized by the failure of both the **anterior and middle columns** (according to Denis’s Three-Column Classification). It is caused by a high-energy **axial loading (vertical compression)** force. This force drives the intervertebral disc into the vertebral body below, causing it to shatter or "burst" outward. A hallmark of this injury is the retropulsion of bone fragments into the spinal canal, which carries a high risk of neurological deficit. **2. Analysis of Incorrect Options:** * **B. Whiplash injury:** This is typically a soft-tissue injury (hyperextension-hyperflexion) of the cervical spine, common in rear-end motor vehicle accidents. It rarely results in a burst fracture. * **C. Wedge compression:** This involves failure of only the **anterior column** due to a flexion-compression force. The posterior cortex of the vertebral body remains intact, making it more stable than a burst fracture. * **D. Avulsion fracture:** This occurs when a ligament or tendon pulls a small fragment of bone away from the main mass (e.g., a "Teardrop" fracture in the cervical spine). It is not caused by axial loading. **3. Clinical Pearls for NEET-PG:** * **Denis Classification:** Burst fractures involve the **Anterior + Middle columns**. * **Radiology:** Look for an **increased interpedicular distance** on an AP X-ray and **retropulsion** of fragments on a CT scan. * **Neurological Risk:** Because the middle column is involved, these fractures are inherently unstable and often require surgical stabilization if there is canal compromise. * **Common Site:** Most frequently occurs at the **Thoracolumbar junction (T12-L1)**.

Question 43: What is the first symptom in tuberculous cord compression?

A. Sensory change
B. Decreased tendon reflex
C. Spasticity (Correct Answer)
D. Lower limb weakness

Explanation: **Explanation:** In Pott’s spine (Tuberculous Spondylitis), cord compression typically occurs due to an abscess, granulation tissue, or bony sequestra. The compression usually occurs from the anterior aspect of the spinal cord, affecting the **Corticospinal tracts** first. **1. Why Spasticity is the Correct Answer:** The earliest clinical manifestation of spinal cord compression in tuberculosis is an **Upper Motor Neuron (UMN)** lesion. The very first sign is often an exaggerated tendon reflex, but the **first subjective symptom** noticed by the patient (or during clinical examination) is **spasticity**. This manifests as a "stiff gait" or a feeling of tightness in the lower limbs. The patient may describe a lack of coordination or "clumsiness" while walking before actual motor power is lost. **2. Why Other Options are Incorrect:** * **Sensory change:** Sensory fibers (Spinothalamic and Posterior columns) are located deeper or more posteriorly and are generally more resistant to pressure than motor fibers. Sensory loss occurs much later in the progression of Pott’s paraplegia. * **Decreased tendon reflex:** This is a feature of a Lower Motor Neuron (LMN) lesion. Since the cord is compressed (CNS), the reflexes become **exaggerated (hyperreflexia)**, not decreased. * **Lower limb weakness:** While weakness (paresis) follows closely, it usually appears after the onset of spasticity. The progression follows the sequence: Spasticity → Muscle Weakness → Complete Paralysis (Paraplegia). **Clinical Pearls for NEET-PG:** * **Sequence of involvement:** Spasticity (earliest) → Motor weakness → Sensory loss → Bladder/Bowel involvement (latest/terminal). * **Most common site:** The **Thoracic spine** is the most common site for Pott’s paraplegia because the spinal canal is narrowest here and the cord has a precarious blood supply. * **Classification:** Remember the **Butler-Seddon classification** for the severity of Pott’s paraplegia, which helps in deciding between conservative management and surgical decompression.

Question 44: A patient presents with a burning sensation in the little toe, and a weak ankle reflex. Which spinal disc herniation is most likely responsible?

A. L5-S1 (Correct Answer)
B. L2-L3
C. L1-L2
D. L4-L5

Explanation: ### Explanation The clinical presentation of a burning sensation in the **little toe** (lateral aspect of the foot) combined with a **weak ankle reflex** (S1 reflex arc) points directly to an **S1 nerve root** compression. **1. Why L5-S1 is correct:** In the lumbar spine, a posterolateral disc herniation typically compresses the **traversing nerve root** (the one exiting at the level below). Therefore, an **L5-S1 disc herniation** compresses the **S1 nerve root**. * **Sensory:** The S1 nerve root supplies the lateral malleolus and the lateral edge of the foot, including the little toe. * **Motor:** It controls plantar flexion (gastrocnemius-soleus complex). * **Reflex:** It mediates the **Achilles (Ankle) reflex**. **2. Why the other options are incorrect:** * **L4-L5 (Option D):** This would compress the **L5 nerve root**. Clinical features include weakness in great toe extension (EHL), foot drop, and sensory loss over the first dorsal web space. The ankle reflex remains intact. * **L2-L3 & L1-L2 (Options B & C):** These are upper lumbar levels. Compression here affects the **L3 or L2 roots**, leading to weakness in hip flexion or knee extension, sensory loss over the anterior thigh, and a diminished **Knee (Patellar) reflex**. **3. Clinical Pearls for NEET-PG:** * **The "Rule of the Root":** Disc herniation at L(X)-L(X+1) affects nerve root (X+1). * **L4 Root:** Weakness in foot inversion; diminished Knee reflex; sensation at medial malleolus. * **L5 Root:** Weakness in Big Toe Extension (EHL); **No specific reflex**; sensation at 1st dorsal web space. * **S1 Root:** Weakness in Plantar flexion; diminished Ankle reflex; sensation at lateral border of foot. * **SLRT (Straight Leg Raising Test):** Most sensitive for L4-L5 and L5-S1 herniations.

Question 45: A 45-year-old female presented with neck pain and stiffness for 3 months. The diagnosis is a spinal condition. Which of the following is NOT an operative treatment for this condition?

A. Intervertebral disc replacement
B. Anterior discectomy and fusion
C. Laminoforaminotomy
D. Posterior decompression (Correct Answer)

Explanation: ### Explanation The clinical presentation of chronic neck pain and stiffness in a 45-year-old is most consistent with **Cervical Spondylosis** or **Cervical Disc Prolapse**. The goal of surgical intervention in these cases is to address the specific pathology (disc herniation or osteophyte) while maintaining spinal stability. **Why "Posterior Decompression" is the correct answer:** In the context of cervical spine surgery, "Posterior Decompression" (like a wide laminectomy) is generally **not** performed as a standalone treatment for simple neck pain or localized disc disease. While it relieves pressure, performing a posterior decompression alone in the cervical spine can lead to **post-laminectomy kyphosis** (instability and deformity). If a posterior approach is used for decompression, it must usually be combined with **instrumented fusion** or performed via specific techniques like laminoplasty to maintain structural integrity. **Analysis of Incorrect Options:** * **Anterior Discectomy and Fusion (ACDF):** This is the **gold standard** surgical treatment for cervical disc disease. It removes the offending disc and stabilizes the segment using a bone graft or cage. * **Intervertebral Disc Replacement (Cervical Arthroplasty):** A modern alternative to ACDF for younger patients (like this 45-year-old) to maintain segmental motion and prevent adjacent segment degeneration. * **Laminoforaminotomy:** A "keyhole" posterior procedure used specifically for lateral disc herniations or foraminal stenosis to decompress the nerve root without destabilizing the entire vertebral arch. **NEET-PG High-Yield Pearls:** * **Most common level affected:** C5-C6 (followed by C6-C7). * **ACDF complication:** Recurrent laryngeal nerve injury (leading to hoarseness) is a classic exam favorite. * **Clinical Sign:** **Spurling’s Test** (neck extension and lateral rotation) is highly specific for cervical radiculopathy. * **Torg-Pavlov Ratio:** A ratio of <0.8 on X-ray indicates developmental canal stenosis.

Question 46: Scheuermann's disease is characterized by which of the following?

A. Osteochondritis of the calcaneum
B. Osteochondritis of the navicular bone
C. Vertebral osteochondritis (Correct Answer)
D. Osteochondritis of the scaphoid bone

Explanation: **Explanation:** **Scheuermann’s disease** is a form of **vertebral osteochondritis** (specifically of the secondary ossification centers of the vertebral bodies). It is a common cause of structural kyphosis in adolescents. The condition occurs due to a growth abnormality of the vertebral endplates, leading to wedge-shaped vertebrae, disc space narrowing, and the characteristic "hunchback" deformity. **Why Option C is correct:** The pathology involves the thoracic or thoracolumbar spine. Diagnosis is confirmed radiologically by **Sorensen’s criteria**: at least three adjacent vertebrae wedged by 5° or more. This fits the definition of osteochondritis affecting the spine. **Why other options are incorrect:** * **Option A (Calcaneum):** Osteochondritis of the calcaneal apophysis is known as **Sever’s disease**. * **Option B (Navicular):** Osteochondritis of the tarsal navicular bone is known as **Kohler’s disease**. * **Option D (Scaphoid):** Osteochondritis of the carpal scaphoid is known as **Preiser’s disease** (though Kienböck’s disease of the lunate is a more common exam topic). **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Sign:** **Schmorl’s nodes** (protrusion of the nucleus pulposus through the vertebral endplate into the adjacent vertebra) are a hallmark finding. * **Clinical Presentation:** Fixed kyphosis that does not disappear on extension (unlike postural kyphosis) and compensatory lumbar lordosis. * **Management:** Conservative (Milwaukee brace) for curves <60°; surgery (posterior fusion) for severe curves >75° or neurological deficits.

Question 47: An 87-year-old woman presents with lower back pain exacerbated by walking or prolonged standing, and occasionally relieved by bending over. Physical examination reveals a thin elderly woman who walks with a cane, with her lower back moderately flexed. Motor power in her lower extremities is normal, but she has impaired sensation to light touch and vibration below the L4 dermatome bilaterally. Deep tendon reflexes are normal in her upper extremities but absent in both lower extremities. MRI of the lumbosacral spine is performed. What will be the most likely finding on this study?

A. Lumbar spinal stenosis (Correct Answer)
B. A fracture of the odontoid process
C. A herniated L3-L4 disk causing unilateral compression of the L4 root
D. Spinal cord compression at the L1 vertebral level

Explanation: The clinical presentation is a classic case of **Lumbar Spinal Stenosis (LSS)**, a common degenerative condition in the elderly. ### 1. Why the Correct Answer is Right The patient exhibits **Neurogenic Claudication**, the hallmark of LSS. The pain is exacerbated by standing or walking (extension of the spine narrows the spinal canal) and relieved by bending forward (flexion increases the canal volume and relieves pressure on the cauda equina)—often referred to as the **"Shopping Cart Sign."** * **Neurological Findings:** Bilateral sensory deficits (L4 and below) and absent lower limb reflexes (areflexia) indicate a lower motor neuron (LMN) pattern consistent with compression of multiple nerve roots in the cauda equina. ### 2. Why Other Options are Wrong * **B. Odontoid Fracture:** This involves the C2 vertebra. It would present with neck pain or upper cervical cord symptoms (quadriparesis/hyperreflexia), not isolated lower back and leg symptoms. * **C. Herniated L3-L4 Disk:** This typically presents with **acute, unilateral** radiculopathy (sciatica). This patient has chronic, bilateral symptoms exacerbated by posture, which points to stenosis rather than a simple disc prolapse. * **D. Spinal Cord Compression at L1:** The spinal cord ends at L1-L2 (Conus Medullaris). Compression here would cause **Upper Motor Neuron (UMN)** signs (hyperreflexia, Babinski sign) or Conus Medullaris syndrome (sudden onset, perianal anesthesia), unlike the LMN signs seen here. ### 3. Clinical Pearls for NEET-PG * **Pathophysiology:** Most commonly caused by hypertrophy of the **Ligamentum Flavum**, facet joint arthropathy, and bulging of the intervertebral discs. * **Diagnosis:** **MRI** is the gold standard investigation. * **Differentiating Claudication:** * **Neurogenic:** Relieved by sitting/leaning forward; pulses are normal. * **Vascular:** Relieved by standing still; pulses are often absent; skin may be trophic/shiny. * **Management:** Conservative initially; **Decompressive Laminectomy** is the surgery of choice if symptoms persist.

Question 48: A 55-year-old male presents with urinary incontinence and severe back pain for 10 days. Imaging shows a lumbar disc prolapse. He has no history of weight loss or fever. What is the diagnosis?

A. Pott's spine
B. Cauda equina syndrome (Correct Answer)
C. Multiple myeloma
D. Guillain-Barré syndrome

Explanation: ### Explanation **Correct Answer: B. Cauda Equina Syndrome (CES)** The clinical presentation of **acute urinary incontinence** (autonomic dysfunction) combined with **severe back pain** and imaging evidence of a **lumbar disc prolapse** is a classic triad for Cauda Equina Syndrome. CES occurs due to the compression of multiple lumbosacral nerve roots below the level of the conus medullaris (usually L2-L5). In this case, the disc prolapse is the mechanical cause of compression. This is a **surgical emergency** requiring urgent decompression to prevent permanent neurological deficits. **Why other options are incorrect:** * **Pott’s Spine (Tuberculosis):** While it causes back pain and potential cord compression, it is typically associated with constitutional symptoms like **fever, weight loss, and night sweats**, which are absent here. * **Multiple Myeloma:** This would be suspected in an older patient with back pain and weight loss (CRAB features), but the acute onset of incontinence following a documented disc prolapse points more directly to a mechanical neurological emergency. * **Guillain-Barré Syndrome:** GBS presents as **acute ascending symmetrical paralysis** with areflexia. While it can involve autonomic dysfunction, it is not associated with lumbar disc prolapse or localized severe mechanical back pain. **High-Yield Clinical Pearls for NEET-PG:** * **Red Flags for CES:** Saddle anesthesia (most specific), bladder/bowel dysfunction (increased urinary frequency or overflow incontinence), and bilateral sciatica. * **Gold Standard Investigation:** MRI Spine (Urgent). * **Management:** Surgical decompression (Laminectomy + Discectomy) ideally within **24–48 hours** of symptom onset. * **Level of Lesion:** It is a **Lower Motor Neuron (LMN)** lesion because the cauda equina consists of peripheral nerve roots.

Question 49: What substance is used for vertebroplasty?

A. Poly methyl methacrylate (Correct Answer)
B. Poly ethyl methacrylate
C. Poly methyl ethacrylate
D. Poly ethyl ethacrylate

Explanation: **Explanation:** **Vertebroplasty** is a minimally invasive image-guided procedure used to treat painful vertebral compression fractures (commonly due to osteoporosis or malignancy). It involves the percutaneous injection of a bone cement to stabilize the fractured vertebra and provide rapid pain relief. **Why PMMA is the Correct Answer:** The substance used is **Poly methyl methacrylate (PMMA)**. It is a medical-grade polymer that acts as a "bone cement." When the liquid monomer is mixed with the powder polymer, an exothermic reaction occurs, causing the substance to harden. This provides immediate structural reinforcement to the weakened vertebral body and alleviates pain by stabilizing microfractures and potentially destroying local nociceptors through the heat generated during polymerization. **Why Other Options are Incorrect:** * **Options B, C, and D:** These are chemical variations (ethyl or ethacrylate derivatives) that do not possess the specific biomechanical properties, biocompatibility, or the extensive clinical track record required for orthopedic use. PMMA remains the gold standard for both vertebroplasty and joint replacement fixation. **High-Yield Clinical Pearls for NEET-PG:** * **Kyphoplasty vs. Vertebroplasty:** Kyphoplasty involves inflating a balloon first to restore vertebral height before injecting PMMA, whereas vertebroplasty involves direct injection. * **Complications:** The most common complication is **cement leakage**. If cement enters the venous system, it can lead to **pulmonary embolism**. * **Contraindications:** Active systemic infection, uncorrected coagulopathy, or a fracture that is asymptomatic. * **Barium Sulfate:** Often added to the PMMA powder to make the cement **radiopaque**, allowing for real-time visualization under fluoroscopy.

Question 50: This defect most commonly involves which region of the spine?

A. Cervico-dorsal
B. Dorso-lumbar
C. Lumbo-sacral (Correct Answer)
D. Atlanto-occipital

Explanation: ***Lumbo-sacral*** - **Spina bifida** most commonly affects the **lumbo-sacral region** because the **neural tube closure** occurs in a cranio-caudal direction, with the **caudal neuropore** being the last to close around day 26-28 of gestation. - This region bears the highest risk for **neural tube defects** due to delayed closure, leading to **myelomeningocele** and associated **lower limb paralysis** and **bladder-bowel dysfunction**. *Cervico-dorsal* - This region undergoes **early neural tube closure** around day 22-24, making defects less common here. - Cervical spina bifida typically presents with **upper limb weakness** and **respiratory complications**, which are less frequently seen. *Dorso-lumbar* - While **thoracic spina bifida** can occur, it's less common than lumbo-sacral involvement due to earlier neural tube closure. - Defects here may cause **paraplegia** but with preserved **upper lumbar function**, unlike the more common lower defects. *Atlanto-occipital* - This represents the **cranio-cervical junction** where **neural tube defects** are extremely rare. - Defects at this level would cause severe **neurological compromise** and are often **incompatible with life** due to involvement of vital centers.

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

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Minimally Invasive Spine Surgery

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Rehabilitation of Spine Conditions

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