Multiple Choice Questions

Spine

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122. Hoffman’s reflex is;

A) pathological
B) positive if there is flexion and adduction of the contralateral thumb
C) a deep tendon reflex
D) associated with hypotonia
E) positive in infants

Correct Answer : C

Hoffman's reflex is a deep tendon reflex .It is normal finding in people with hypertonia .

Author: David Hughes

 

121. In cervical spine stenosis, the risk of neurological deficit increases with a Pavlov-Torn ratio of?

A) <0.8
B) 0.8 – 1.0
C) 1.0 – 1.2
D) 1.2 – 1.4
E) >1.4

Correct Answer : A

Pavlov-Torg ratio is the ration of sagittal diameter of cervical spinal canal to the sagittal diameter of the vertebral body. 

A ratio of less than 0.8 is considered critical stenosis and is associated with increased risk of neurological deficit.

Author: Pranav D. Shah

 

 
120. The lesion indicated in this computed tomography most likely represents:

A) Brodie’s abscess
B) Eosinophilic granuloma
C) Osteosarcoma
D) Osteoid osteoma
E) Osteoma

Correct Answer : D

Epiphyseal osteochondroma is also known as Trevor’s disease. 

Epiphyseal osteochondroma is localized to a specific region of the body, unlike multiple osteochondroma, which affects the entire body. Epiphyseal osteochondroma and multiple osteochondroma are unrelated disorders.

Author: Rajesh Bahadur Lakhey

 

119. The radiographic line delimiting the foramen magnum that is used in determining basilar invagination is the:

A) McGregor line
B) McRae line
C) Chamberlain line
D) Ranawat line
E) Swischuk line

Correct Answer : B

The McRae line is from the anterior to the posterior lip of the foramen magnum. Protrusion of the odontoid above this line indicates basilar invagination. 
The McGregor and Ranawat lines are also used to evaluate basilar invagination. 
The Swischuk line is from the posterior cortex of C1 to C3 lamina and is used in evaluating pseudosubluxation.

Author: Rajesh Bahadur Lakhey

 

118. For a patient who has thoracic idiopathic scoliosis of the surgical range, the distance between the thecal sac and the apical thoracic pedicle on the concave side is:

A) Less than 1 mm
B) 2 mm
C) 3 mm
D) 4 mm
(E) 5 mm

Correct Answer : A

The distance between the apical thoracic pedicle and the thecal sac is less than 1 mm on the concave side.

Author: Rajesh Bahadur Lakhey

 

117.Which of the following disorders is due to a defect in anterior horn cells:

A) Charcot-Marie-Tooth
B) Duchenne dystrophy
C) Friedreich’s ataxia
D) Spinal muscular atrophy
E) Rett syndrome

Correct Answer : D

Charcot-Marie-Tooth disease is due to a defect in peripheral nerves; Duchenne muscular dystrophy is due to a defect in dystrophin, affecting the muscle cell membrane; Friedreich ataxia is a degeneration of the spinocerebellar tracts. Rett syndrome is due to a defect in MECP-2 protein, affecting the brain. Only spinal muscular atrophy is due to a defect in anterior horn cells.

Author: Rajesh Bahadur Lakhey

 

116. A magnetic resonance image of a 7-year-old girl shows a line of high-signal intensity within the cord on T2 sequences that parallels the ventral surface of the cord and appears as a syrinx. However, on the axial images and on the T1 sequences, this finding is not evident. The most likely diagnosis is:

A) Collapsing syrinx
B) Gibbs artifact
C) Motion artifact
D) Ependymoma
E) Astrocytoma

Correct Answer :B

A Gibbs artifact is a linear focus in the cord on T2-weighted images that parallels the ventral aspect of the cord and mimics a syrinx. The Gibbs artifact is due to the linear interface between two tissues of differing signal intensity. It is not seen on axial images or T1-weighted images.
    • Motion artifact is a blurring of the image due to patient motion, respiration, or cerebral spinal fluid pulsation.
    • Ependymoma and astrocytoma are seen on both the axial and the sagittal images.

Author: Rajesh Bahadur Lakhey

 

115. A posterior spine fusion with segmental hook fixation from T4-L4 is performed for idiopathic scoliosis in a 15-year-old girl. Somatosensory evoked potential monitoring is normal throughout the procedure. 

The patient awakens and is unable to move either lower extremity, but she does have some sensation in the lower extremities. 

Recommended treatment includes:

 A) Removal of instrumentation
B) Myelogram
C) Laminectomy above the conus medullaris
D) Administration of corticosteroids and observation for 6 hours
E) Full heparinization of the patient

Correct Answer : A

Spinal cord injury occurs in approximately 1% of patients operated upon for idiopathic scoliosis. In some cases, sensory spinal cord monitoring may be unchanged, especially if the injury preserves the dorsal columns. 

The instrumentation should be removed as soon as possible in case spinal traction or derotation or implant protrusion is producing effects on the cord or its blood supply.

Corticosteroids should be administered at spinal cord injury doses, but this should not be the only measure.

Obtaining a myelogram may delay the removal of instrumentation and should not be the first step.

Heparinization has no proven effect.

Author: Rajesh Bahadur Lakhey

 

114. A 14-year-old girl is examined because of a pain in her left flank. 

The radiographs of the lumbar spine show loss of the pedicle with expansion of the lateral wall of the third lumbar vertebral body. 

Magnetic resonance imaging shows multiple fluid levels in the vertebral body with no additional areas of involvement. 

She is neurologically normal. Recommended treatment includes:

A) Observation
B) Radiation therapy
C) Selective arterial embolization
D) Radical en bloc resection
E) Curettage plus radiation therapy

Correct Answer: C

This patient has an aneurysmal bone cyst of the vertebra. 

Selective arterial embolization is a minimally invasive treatment that often succeeds in arresting the lesions. Many times it is the only treatment needed. Selective arterial embolization can also be used as part of a strategy to be followed by curettage and reconstruction to decrease operative bleeding.
    • This lesion will continue to expand and might cause neurologic compromise or mechanical instability.
    • Radiation therapy poses risks of later malignant degeneration. There are other ways of treating this lesion.
    • Radical en bloc resection may unnecessarily injure neurologic structures.
    • While curettage is often necessary, there is no reason to introduce the risk of radiation therapy.
Author: Rajesh Bahadur Lakhey

 

113. Which of the following is not a specific feature in making the diagnosis of a dystrophic curve in neurofibromatosis 1:

A) Penciling of the ribs
B) Scalloping of the vertebrae
C) Widening of the foramen
D) Thinning of the transverse processes
E) Vertebral rotation

Correct Answer: E

Vertebral rotation is not a specific characteristic of dystrophic curves. Rotation is more pronounced in dystrophic curves than in nondystrophic curves, but it is commonly present in both types of curves.
    • Penciling of the ribs is one of the features specific for dystrophic curves in neurofibromatosis 1. 

    • Scalloping of the vertebrae anteriorly and posteriorly is characteristic of dystrophic curves in neurofibromatosis 1.
    • Widening of the neural foramen is specific for dystrophic curves in neurofibromatosis 1. Widening of the neural       foramen is due to tumorous masses passing through the foramen.
    • Thinning of the transverse process is a characteristic of dystrophic curves in neurofibromatosis 1.

Author of the question: Rajesh Bahadur Lakhey

 

112. Which of the following descriptions is more characteristic of tuberculosis than pyogenic spondylitis:

A) Disc space is narrowed before significant bony changes occur.
B) Involvement of multiple contiguous levels is uncommon.
C) Bony erosions seen on computerized tomography are usually small and focal.
D) Vertebral destruction exceeds disc destruction.
E) Magnetic resonance imaging rarely shows significant soft tissue swelling.

Correct Answer : D

Vertebral destruction exceeds disc destruction in tuberculosis.

  • Bony changes occur earlier in tuberculosis than in pyogenic spondylitis.
  • Involvement of multiple contiguous levels is more common in tuberculosis than pyogenic spondylitis.
  • Bony erosions seen on computerized tomography are large in tuberculosis and small in pyogenic spondylitis.
  • Magnetic resonance imaging often shows significant soft tissue involvement in both disorders.

Author: Rajesh Bahadur Lakhey

 

111. Adolescent girls with multiple radiographs for idiopathic scoliosis are statistically at increased risk for which of the following problems later in life:

(A) Lung cancer
(B) Breast cancer
(C) Lymphoma
(D) Leukemia
(E) Squamous carcinoma

Correct Answer : B

In a historical cohort study, the risk was increased to 1.7 times the expected rate of breast cancer. The radiation dose is currently lower. The exposure to the breast may be lowered by tanking posteroanterior rather than anteroposterior films, and eliminating lateral films in routine situations.

Author: Rajesh Bahadur Lakhey

 

110. Forty percent of osteoblastomas involve the axial skeleton. 

Which of the following statements is true:

(A) The vertebral body is the most common location
(B) The posterior elements are the most common site
(C) The presence of aneurysmal bone cyst changes within the lesion is rare
(D) Neurologic symptoms are unusual
(E) Patients are generally over 50 years of age

Correct Answer : B

commonly occur in the spine. The lesions involve the posterior elements, may cause neurologic symptoms, and

commonly occur in young patients.
The following statements are true concerning osteoblastomas of the spine:
Neurologic symptoms are common.
Expansion of the posterior elements is common.
Aneurysmal bone cyst-like changes are commonly seen histologically.
The patients are generally young.

Author of the question: Rajesh Bahadur Lakhey

 

109. The skin of the proximal one-third of the anterior thigh just distal to the inguinal ligament is innervated by which of the following levels

(A) T12
(B) L1
(C) L2
(D) L3
(E) L4

Correct Answer : B

The skin of the proximal one-third of the anterior thigh just distal to the inguinal ligament is
innervated by L1, L2, and L3.
Note:
L1 Thigh, proximal third, anterior
L2 Thigh, middle, anterior
L3 Thigh, distal third, anterior

Author : Rajesh Bahadur Lakhey

 

108. The Achilles tendon reflex (ankle reflex) is transmitted through which of the following nerve roots

(A) L4
(B) L5
(C) S1
(D) S2
(E) S3

Correct Answer: C

The Achilles tendon reflex is based upon the triceps muscle group (medial and lateral
gastrocnemius muscles and soleus muscle) and is transmitted through the S1 nerve root.
Note the reflexes and the associated nerve roots:
Patellar tendon reflex –  L4
Posterior tibial reflex – L5
Achilles tendon reflex – S1

 

107. The tibialis anterior muscle is principally innervated by which of the following segmental levels

(A) L1
(B) L2
(C) L3
(D) L4
(E) L5

Correct Answer: D

The tibialis anterior muscle is primarily innervated by the L4 nerve root. The tibialis anterior muscle also receives innervation from L5. Patients with a weak or absent tibialis anterior muscle will have a drop foot or a steppage gait. The tibialis anterior muscle causes dorsiflexion and inversion of the foot and ankle.

Author : Rajesh Bahadur Lakhey

 

106. The patellar tendon reflex is primarily transmitted through which of the following nerve roots:

(A) L1
(B) L2
(C) L3
(D) L4
(E) L5

Correct Answer: D

Although the patellar tendon reflex is primarily transmitted through the L4 nerve root, the L2 and L3 nerve roots also contribute to the fibers. There is a weak reflex if the L4 nerve root is completely cut, even if there are still L2 and L3 fibers. 

Patellar tendon reflex is seldom completely absent unless the patient has primary muscle or anterior horn lesions.

Author : Rajesh Bahadur Lakhey

 

105. A 75-year-old woman presents with low back pain that is worse with motion , and bilateral lower extremity pain that is worse with ambulation. She notes that the pain extends down the posterior aspects of her lower extremities, from the buttocks to her calves. The pain limits her activity , she can only ambulate approximately one block before having to rest. She reports that lumbar flexion, notably leaning over a walker or a shopping cart, considerably diminishes her lower extremity pain. She has a significant past medical history of coronary artery disease, and she has had previous angioplasty of her coronary vessels. 

On examination, her lower extremity pulses are easily palpable. 

This patient’s magnetic resonance image findings are most indicative of:

A) Central stenosis
B) Lateral recess stenosis
C) Central herniated nucleus pulposis
D) Lateral herniated nucleus pulposis
E) Far lateral herniated nucleus pulposis

Correct Answer: B

This patient’s sagittal imaging clearly shows significant stenosis at L4-L5, with minimal, if any, disease at other
levels. The stenosis is severe. 

The pars is not visualized on the sagittal imaging. Therefore, the diagnosis of an isthmic spondylolisthesis cannot be made. 

The axial T2 images (Slide 1) reveal significant lateral recess stenosis. 

The central stenosis on these images is not as impressive. 

Although there is a broad-based disk bulge at the L4-L5 level, this is not as significant as the lateral recess stenosis

Author: Rajesh Bahadur Lakhey

 

104. A 45-year-old man has neck pain following a motor vehicle accident. 

His neurologic examination is normal. 

His plain radiographs are shown (Slide). The most likely diagnosis is:

A) Cervical strain (whiplash-type injury)
B) Compression fracture of C5
C) Unilateral facet dislocation
D) Bilateral facet dislocation
E) Spinous process fracture

Correct Answer: C

The lateral radiograph shows translation and kyphosis at the level of injury. The facets of C4 do not
superimpose on each to create a "double sail" sign. This patient has a unilateral facet dislocation. With
unilateral facet dislocations, there is usually 3 mm to 4 mm of forward translation and 5° to 7° of angulation.

Author: Rajesh Bahadur Lakhey

 

103. All of the following are possible treatments for congenital or acquired torticollis except:

A) No treatment because spontaneous resolution is possible in cases of congenital torticollis
B) Active and passive stretching therapies in patients with congenital torticollis until puberty
C) Holding infants so that chin is rotated toward the affected side
D) Physical therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and use of a soft collar
E) Use botulinum toxin, hard collars, or braces in severe cases

Correct Answer: B

In very mild cases of congenital torticollis, the deformity may be self-limited and no therapy needs to be administered. Sometimes active and passive stretching of the neck can work well if performed before 1 year of life. Parents may hold the baby’s head so that the chin is rotated toward the affected side. 

Acquired torticollis can also be managed by physical therapy using NSAIDs and a soft collar.

Author: Rajesh Bahadur Lakhey

 

102. Schmorl’s nodes may be seen on radiographic studies in all of the following disorders except:

A) Spina bifida
B) Scheuermann’s kyphosis
C) Degenerative disk disease
D) Trauma
E) Osteoporosis

Correct Answer: A

Schmorl’s nodes are seen in association with several disorders including Scheuermann’s kyphosis, degenerative disk
disease, trauma, and osteoporosis. 

Schmorl’s nodes are not commonly seen in patients with spina bifida.

Schmorl&#39;s nodes - Wikipedia

Author: Rajesh Bahadur Lakhey

 

101. Which of the following statements concerning neck pain is incorrect:

A) Patients with traumatic neck injury and pain must be immoblized and assessed with a full neurologic examination
B) Elderly patients may have symptoms of traumatic neck injury without a history of trauma.
C) Rest, physical therapy, and prolonged immobilization of the neck with a collar are effective in managment
D) Surgery for neck pain may be indicated for patients with a cervical spine fracture with evidence of instability, neoplastic disorders, spinal stenosis, and nerve root compression.
(E) Rest and physical therapy

Correct Answer: C

Choices A, B, D, and E are correct and are important considerations with managing a patient with neck pain. 

Rest and physical therapy are important and effective in treating neck pain. 

Prolonged immobilization of the neck with a collar, however, can result in deconditioning of the cervical paraspinal musculature, which can increase the patient’s risk for further neck injury.

Author: Rajesh Bahadur Lakhey

 

100. Studies suggest that cervical radiculopathy of which nerve root may partially explain the phenomenon of cervicogenic headaches:

A) C3
B) C4
C) C5
D) C6
E) C7

Correct Answer: A

Headaches observed with upper cervical pathology may be dueto the convergence of C1-, C2-, and C3-level
pain fibers with  neurons of the descending sensory tract of cranial nerve V.

Author: Rajesh Bahadur Lakhey

 

99. Which of the following spinal fracture types is the most stable fracture:

A) Teardrop fracture
B) Burst fracture
C) Unilateral facet dislocation
D) Hangman’s fracture
E) Clay-shoveler’s fracture

Correct Answer: E

The avulsion of part or all of the spinous process that occurs after a violent flexion motion is a one-column injury. The
injury is a stable fracture treated by external orthosis.

The other answer choices may be considered stable in some instances, but none of them are stable all of the time.

Author: Rajesh Bahadur Lakhey

 

98. To avoid vertebral artery injury during cervical lateral mass screw placement, it is best to:

A) Start at the midpoint and aim the screw laterally
B) Start at the midpoint and aim the screw medially
C) Start medially and aim the screw perpendicular
D) Start medially and aim the screw medially
E) Start laterally and aim the screw medially

Correct Answer: A

To avoid injury to the vertebral artery when placing lateral mass screws, it is best to avoid placing the screw in the
medial portion of the lateral mass, where the vertebral artery is most likely to be found.

Author: Rajesh Bahadur Lakhey

 

97. All of the following are elements of the lateral mass of cervical spinal segments except:

A) Inferior articulating process
B) Superior articulating process
C) Spinous process
D) Transverse process
E) Transverse foramen

Correct Answer: C

The lateral mass of the cervical spinal segments includes the inferior and superior articulating processes, the transverse foramen, and the transverse process. 

The spinous process is not an element of the lateral mass.

The Cervical Spine - Features - Joints - Ligaments - TeachMeAnatomy

Author: Rajesh Bahadur Lakhey

 

96. Which of the following statements is false regarding minimally invasive transperitoneal anterior lumbar interbody
fusion:

A) This technique may be safely performed at all lumbar levels.
B) This technique allows direct access to pathology in the vertebral body.
C) Laparoscopy is of great value in the transperitoneal approach to the anterior lumbar spine.
D) There is a potential risk of injuring the aorta and its bifurcation with this technique.
E) None of the above

Correct Answer: A

Due to the potential risk of injury to the aorta and its bifurcation, which occurs at the L4 level, this procedure is difficult and may be impossible to perform above the L4 level. 

Retroperitoneal approaches allow access to more superior lumbar levels due to the more lateral trajectory taken to avoid the aorta and its bifurcation.

Author: Rajesh Bahadur Lakhey

 

95. Which of the following serves as the best landmark for proper screw entry into the lumbar pedicle:

A) The junction of the transverse process and inferior facet
B) The junction of the transverse process and superior facet
C) The articulating interface of the superior and inferior facets
D) The medial border of the superior facet
E) There is no relationship between the nerve root and the superior facet

Correct Answer: A

The junction of the transverse process and the inferior facet represents the most appropriate entry point of the pedicle screw. This junction directly overlies the pedicle and ensures safe placement through the pedicle and into the vertebral body.

Author: Rajesh Bahadur Lakhey

 

94. In relation to the lumbar pedicle, the exiting nerve root is found:

A) Immediately superior to the pedicle
B) Immediately inferior to the pedicle
C) At the midpoint between the superior and inferior level pedicles
D) Nerve root has no anatomic relationship to the pedicle
E) None of the above

Correct Answer: B

The exiting nerve root is found traversing immediately inferior to the pedicle.

Author: Rajesh Bahadur Lakhey

 

93. Patients with anterior cord syndrome usually present with:

A) Preservation of motor function, preservation of pain and temperature sensation, and loss of vibration and touch sensation
B) Preservation of motor function, with loss of pain, temperature, vibration, and touch sensation
C) Motor paralysis, loss of pain, temperature, vibration, and touch sensation
D) Motor paralysis, loss of pain and temperature sensation, and preservation of vibration and touch sensation
E) Motor paralysis, loss of vibration and touch sensation, and preservation of pain and temperature sensation

Correct Answer: D

Anterior cord syndrome is due to injury of the anterior elements of the spinal cord, which is usually due to a
space-occupying lesion anterior to the cord such as vertebral body fracture fragments, a herniated disk, or a
hematoma. 

The clinical presentation consists of:
* Complete motor paralysis (loss of anterior corticospinal tract)
* Loss of pain/temperature sensation (loss of lateral and anterior spinothalamic tracts)
* Preservation of vibration sensation/proprioception and light touch sensation (preservation of dorsal columns)
In less severe cases, some motor function is preserved through the lateral corticospinal pathways. 

Prognosis is generally poor and in patients with absence of sacral sensation (pin prick/temperature) after 24 hours following injury, recovery is seen in only 10% of patients.

Author: Rajesh Bahadur Lakhey

 

92. In reference to the normal sagittal vertical axis (sagittal plumb line), the axis normally falls from the odontoid process through the C7-T1 intervertebral disk and anterior to the thoracic vertebrae. 

This normal axis crosses the spinal column at which of the following levels before crossing at the posterior superior border of the S1 vertebral body:

A) T3-T4 intervertebral disk
B) T6-T7 intervertebral disk
C) T8-T10 intervertebral disk
D) T12-L1 intervertebral disk
E) L3-L4 intervertebral disk

Correct Answer: D

The alignment of the spine is important in normal upright posture. There is a normal degree of lordosis in the
cervical and lumbar spines and a moderate degree of kyphosis in the thoracic spine. 

The head, spine, and pelvis are connected and balanced. If the spine is out of balance, then a deformity can develop causing fatigue of the paraspinal muscles.

The sagittal plumb line falls from the odontoid process through the C7-T1 intervertebral disk and then
anterior to the thoracic spine. The plumb line then crosses the spine at the T12-L1 intervertebral disk,
and then travels posterior to the spine. The plumb line crosses at the posterior corner of the S1
vertebra.
The endplates and pedicles of the L3 vertebra are normally parallel to the ground.

Adult / Fixed Sagittal Imbalance | Prof. Youssry Elhawary

Author: Rajesh Bahadur Lakhey

 

 

91 The endplates and pedicles of which of the following vertebra are normally parallel to the ground in a standing individual:

A) L1
B) L3
C) S1
D) T1
E) T12

Correct Answer: B

The alignment of the spine is important in normal upright posture. There is a normal degree of lordosis in the
cervical and lumbar spines and a moderate degree of kyphosis in the thoracic spine. The head, spine, and
pelvis are connected and balanced. If the spine is out of balance, then a deformity can develop causing fatigue
of the paraspinal muscles.
The normal sagittal alignment in the upright patient is as follows:
* Plumb line
The sagittal plumb line falls from the odontoid process through the C7-T1 intervertebral disk and then
anterior to the thoracic spine. The plumb line then crosses the spine at the T12-L1 intervertebral disk,
and then travels posterior to the spine. The plumb line crosses at the posterior corner of the S1
vertebra.
The endplates and pedicles of the L3 vertebra are normally parallel to the ground.

Author: Rajesh Bahadur Lakhey

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