Spine Disorders

Spine Disorders Indian Medical PG Question 1: A 50-year-old male presents with chronic low back pain that has failed physical therapy and conservative measures. MRI shows disc herniation at L5-S1 with radiculopathy. What is the next step in management?

• A. Epidural steroid injection (Correct Answer)
• B. Surgical decompression
• C. Acupuncture
• D. NSAIDs

Spine Disorders Explanation: ***Epidural steroid injection*** - This is often the appropriate **next step** for radiculopathy from disc herniation that has failed conservative management, as it can reduce **inflammation** and pain at the nerve root. - It helps manage pain and allows patients to engage more effectively in **physical therapy**. *Surgical decompression* - This is typically considered after **less invasive methods** like epidural steroid injections have failed, especially if there are progressive neurological deficits or intractable pain. - While it can relieve nerve compression, it carries higher risks than injections and is not the immediate next step after failure of basic conservative measures. *Acupuncture* - While acupuncture can be used as an **adjunctive therapy** for chronic pain, it is not primary management for symptomatic disc herniation with radiculopathy that has failed physical therapy. - There is limited evidence to support its effectiveness in resolving nerve compression or significant radicular symptoms. *NSAIDs* - **NSAIDs** are part of the initial conservative management for low back pain and disc herniation. - Since the question states that **conservative measures have failed**, continuing or restarting NSAIDs alone would likely be ineffective and is not the next step.

Spine Disorders Indian Medical PG Question 2: A lesion in the cauda equina will likely present with what type of signs?

• A. Lower motor signs (Correct Answer)
• B. Spastic paralysis
• C. Hyperreflexia
• D. Upper motor signs

Spine Disorders Explanation: Lower motor signs - The **cauda equina** consists of nerve roots that have **exited the spinal cord** proper, making them part of the **peripheral nervous system**. [2] - Damage to these peripheral nerves results in **lower motor neuron deficits** such as **flaccid paralysis**, **areflexia**, and **muscle atrophy**. [1] *Spastic paralysis* - **Spastic paralysis** is characteristic of **upper motor neuron lesions**, not lesions affecting the peripheral nerves of the cauda equina. - This condition involves increased muscle tone and hyperreflexia due to the disinhibition of spinal reflexes. *Hyperreflexia* - **Hyperreflexia** is typically a sign of an **upper motor neuron lesion**, indicating damage to the neural pathways above the level of the spinal reflex arc. [2] - Lesions of the cauda equina, being lower motor neuron lesions, usually present with **hyporeflexia** or **areflexia**. *Upper motor signs* - **Upper motor neuron signs** (e.g., spasticity, hyperreflexia, positive Babinski sign) arise from damage to the motor pathways within the **brain** or **spinal cord**. - The cauda equina, comprising nerve roots **distal to the spinal cord termination** (conus medullaris), is part of the peripheral nervous system, and its lesions produce lower motor neuron signs. [1]

Spine Disorders Indian Medical PG Question 3: A 50-year-old male with a history of chronic low back pain presents with new-onset bowel and bladder incontinence. What is the next best step in management?

• A. Conservative management with NSAIDs
• B. Bed rest
• C. Urgent MRI of the spine (Correct Answer)
• D. Physical therapy

Spine Disorders Explanation: ***Urgent MRI of the spine*** - The new onset of **bowel and bladder incontinence** in a patient with chronic low back pain is highly suggestive of **cauda equina syndrome**. This is a surgical emergency. - An **urgent MRI** is crucial to confirm the diagnosis and identify the level of compression, guiding immediate surgical decompression to prevent permanent neurological deficits. *Conservative management with NSAIDs* - This approach is appropriate for routine, uncomplicated low back pain, but it is entirely inadequate for a **neurological emergency** like potential cauda equina syndrome. - Delaying definitive diagnosis and treatment in such cases can lead to irreversible neurological damage, including chronic incontinence and paralysis. *Bed rest* - While bed rest might be recommended for acute exacerbations of certain types of back pain, it is not a primary treatment for neurologic emergencies and will not resolve the underlying compression causing **cauda equina syndrome**. - Prolonged bed rest can also lead to complications like deconditioning and venous thromboembolism, and it would waste critical time for diagnosis and intervention. *Physical therapy* - Physical therapy is a cornerstone of management for chronic low back pain and for rehabilitation after an acute event once stability is achieved. - However, in cases of suspected **cauda equina syndrome**, physical therapy is contraindicated as an initial step because it does not address the acute spinal cord or nerve root compression and may worsen the condition or delay necessary surgical intervention.

Spine Disorders Indian Medical PG Question 4: A patient presents with a suspected cervical spine injury following an accident. What is the first step in management?

• A. perform imaging studies
• B. administer oxygen
• C. stabilize the cervical spine (Correct Answer)
• D. log roll the patient

Spine Disorders Explanation: ***stabilize the cervical spine*** - In any suspected cervical spine injury, the **first and most critical step is to stabilize the cervical spine** to prevent further neurological damage. This is achieved through manual inline stabilization, followed by a **rigid cervical collar** and placement on a backboard. - This immediate stabilization is paramount before any other assessments or interventions that could potentially worsen the injury. *perform imaging studies* - While imaging studies (e.g., X-ray, CT scan) are crucial for diagnosing the extent of cervical spine injury, they should only be performed **after the spine has been adequately stabilized**. - Performing imaging prior to stabilization risks **further displacement** of vertebrae and spinal cord injury. *administer oxygen* - Administering oxygen is an important step in **maintaining adequate oxygenation** and is part of initial resuscitation, but it does not take priority over cervical spine stabilization in a trauma setting. - **Airway, Breathing, Circulation (ABC)** management should always incorporate cervical spine protection. *log roll the patient* - **Log rolling** is a technique used to move a patient with a suspected spinal injury, but it must be performed **only after the cervical spine is stabilized** and with sufficient personnel to ensure coordinated movement. - Log rolling is not the first step in management; rather, it is a technique for patient assessment and transfer once initial stabilization is achieved.

Spine Disorders Indian Medical PG Question 5: A 33-year-old man is brought to the emergency department after being involved in a major motor vehicle accident. He is unable to move his legs and complains of severe pain in his mid to lower back. On physical examination, he is found to have exquisite tenderness over some of the bony prominence of his lower back, but no gross physical deformity can be appreciated. On neurologic examination, flaccid paralysis of both lower extremities and complete anesthesia to all sensory modalities below approximately the L3 dermatome are noted. Catheterization of his bladder yields approximately 700 mL of urine. Plain radiographs of the spine reveal compression fracture in the body of L3 with greater than 50% of loss in its height. A computed tomography (CT) scan through this area reveals a burst fracture of the body of L3. There are large fragments of bone driven dorsally with an 80% canal compromise. What is the cause of weakness?

• A. Compression of the cauda equina (Correct Answer)
• B. Compression of the conus medullaris
• C. Rupture of the anterior spinal ligament
• D. Compression of the spinal cord at the level of L3

Spine Disorders Explanation: ***Compression of the cauda equina*** - The patient's presentation with flaccid paralysis of both lower extremities and complete anesthesia below L3, along with a **burst fracture of L3** and significant **canal compromise**, is consistent with **cauda equina syndrome**. The spinal cord typically ends at the L1-L2 vertebral level, so an injury at L3 would affect the cauda equina nerve roots. - The **cauda equina** consists of lumbar and sacral nerve roots that innervate the lower extremities and bladder, explaining the incontinence (700 mL of urine retention) and neurological deficits observed. *Compression of the conus medullaris* - The **conus medullaris** is the tapered end of the spinal cord, located around the T12-L2 vertebral levels. While an injury at this level can cause similar neurological deficits, the L3 fracture is below this point. - Compression of the conus medullaris often presents with a more **symmetrical and sudden onset** of symptoms, and the specific vertebral level of injury makes cauda equina more likely here. *Rupture of the anterior spinal ligament* - A rupture of the **anterior spinal ligament** alone would primarily lead to **spinal instability** and potentially pain, but it does not directly explain flaccid paralysis and anesthesia below L3. - While ligamentous injury often accompanies fractures, the neurological deficits are due to **compression of neural structures**, not the ligament itself. *Compression of the spinal cord at the level of L3* - The **spinal cord typically terminates** at the L1-L2 vertebral level in adults, forming the conus medullaris, and then continues as the cauda equina. - Therefore, compression at the L3 level would not directly involve the spinal cord itself but rather the **nerve roots of the cauda equina**.

Spine Disorders Flashcard 1 of 5

Question: _____ classification is used for classifying spondylolisthesis based on the cause

Answer: Wiltse-Newman

Spine Disorders Flashcard 2 of 5

Question: According to the Denis classification, _____ column is the anterior part of the vertebra and disc, and the anterior longitudinal ligament

Answer: anterior

Spine Disorders Flashcard 3 of 5

Question: _____ is used to describe degenerative findings in the adjacent vertebral endplates due to age-related skeletal changes or osteophyte formation.

Answer: Spondylosis

Spine Disorders Flashcard 4 of 5

Question: Spinal stenosis is most commonly due to _____ of the spine, whereupon the ligamentum flavum hypertrophies and compresses nerve roots

Answer: osteoarthritis

Spine Disorders Flashcard 5 of 5

Question: _____ classification and the subaxial cervical spine injury classification (SLIC) is used for subaxial (C3-C7) cervical injuries

Answer: Ferguson and Allen