Back Practice Questions

Q: All are pierced in Lumbar Puncture except:

Posterior longitudinal ligament. ***Posterior longitudinal ligament*** - The **posterior longitudinal ligament** runs along the **posterior surface of the vertebral bodies**, forming the **anterior wall of the spinal canal**. - A lumbar puncture needle **does not reach this ligament** as it enters from the **posterior aspect** of the spinal canal. *Interspinous Ligament* - The **interspinous ligament** is located between the **spinous processes of adjacent vertebrae**. - It is **pierced** during a lumbar puncture as the needle advances through the posterior elements to reach the spinal canal. *Ligamentum Flavum* - The **ligamentum flavum** connects the **laminae of adjacent vertebrae**. - This ligament is **pierced** by the needle just before it enters the epidural space and then the subarachnoid space during a lumbar puncture. *Supraspinous ligament* - The **supraspinous ligament** runs along the tips of the **spinous processes**. - It is the **first ligament pierced** by the needle as it enters the skin and subcutaneous tissue during a lumbar puncture.

Q: A 7-year-old female who is somewhat obese is brought to the emergency department because of a soft lump above the buttocks. Upon physical examination you note the lump is located just superior to the iliac crest unilaterally on the left side. The protrusion is deep to the skin and pliable to the touch. Which of the following is the most probable diagnosis?

Herniation at the lumbar triangle (of Petit). ***Herniation at the lumbar triangle (of Petit)*** - This hernia occurs through the **lumbar triangle of Petit**, which is bounded by the **latissimus dorsi**, **external oblique**, and **iliac crest**. - Its location just **superior to the iliac crest** and unilateral presentation align with the description of a lumbar hernia, often presenting as a soft, pliable lump. *Indirect inguinal hernia* - This type of hernia protrudes through the **deep inguinal ring** and often descends into the scrotum or labia, a location not consistent with a lump above the buttocks. - It is typically associated with a **patent processus vaginalis**, more common in infants and young children, but the described location differs significantly. *Tumor of the external abdominal oblique muscle* - While possible, a **tumor** would likely present with different characteristics, such as being firm, fixed, and potentially painful, rather than a soft, pliable protrusion. - The described soft and pliable characteristics are more indicative of a hernia involving abdominal contents rather than a solid muscle mass. *Direct inguinal hernia* - A direct inguinal hernia protrudes through the **Hesselbach's triangle** and appears medially to the inferior epigastric vessels, typically presenting as a bulge in the groin area. - Its location in the **anterior abdominal wall**, near the pubic tubercle, makes it inconsistent with a lump found superior to the iliac crest.

Q: All are TRUE about intervertebral disc, EXCEPT:

Rich vascular supply. ***Rich vascular supply*** - The intervertebral disc is largely **avascular** in adults, receiving nutrients primarily through diffusion from the vertebral bodies. - This lack of direct blood supply is why it has a limited capacity for self-repair and healing after injury. *Prolapse is most common in lumbosacral region* - The **lumbosacral region** (L4-L5 and L5-S1) bears the most weight and experiences the greatest biomechanical stress, making it the most common site for disc prolapse or herniation [1]. - This area is prone to injury due to the demands placed upon it during movement and lifting. *Nucleus pulposus is a remnant of notochord* - The **nucleus pulposus**, the gelatinous center of the intervertebral disc, is indeed a direct remnant of the embryonic **notochord**. - This embryological origin explains its high water content and elastic properties, which allow it to function as a shock absorber. *Annulus fibrosus is made up of fibrocartilage* - The **annulus fibrosus** is the tough outer layer of the intervertebral disc composed of concentric layers of **fibrocartilage**. - These collagen fibers are arranged in a crisscross pattern to provide strength and contain the nucleus pulposus.

Q: Membrana tectoria is continuation of:

Posterior longitudinal ligament. ***Posterior longitudinal ligament*** - The **membrana tectoria** is a broad, strong membrane that is the superior continuation of the **posterior longitudinal ligament**. - It extends from the body of the **axis (C2)** to the **basilar part of the occipital bone**, covering the dens and its associated ligaments. *Anterior atlanto-occipital membrane* - This membrane is a continuation of the **anterior longitudinal ligament** superiorly, connecting the anterior arch of the atlas to the anterior margin of the foramen magnum. - It is located **anterior** to the vertebral column, while the membrana tectoria is posterior. *Anterior longitudinal ligament* - This ligament runs along the **anterior surfaces of the vertebral bodies** and intervertebral discs from the atlas to the sacrum. - Its superior continuation is the **anterior atlanto-occipital membrane**, not the membrana tectoria. *Posterior atlanto-occipital membrane* - This membrane connects the **posterior arch of the atlas** to the posterior margin of the foramen magnum. - It is distinct from the membrana tectoria, which lies **deep** to it and is a continuation of the posterior longitudinal ligament.

Q: Which of the following parts of the vertebral canal shows the first secondary curve to develop?

Cervical Vertebral Canal. ***Cervical Vertebral Canal*** - The **cervical curve** is the **first secondary curve** to develop as an infant learns to hold their head up (around 3-4 months). - This **lordotic curve** is concave posteriorly and helps to balance the head on the vertebral column. - It develops before the lumbar curve, making it the earliest secondary curvature. *Lumbar Vertebral Canal* - The **lumbar curve** is also a **secondary curve** but develops later when an infant begins to stand and walk (around 12-18 months). - It is a **lordotic curve**, concave posteriorly, and helps maintain an upright posture. - This is the second secondary curve to develop. *Thoracic Vertebral Canal* - The **thoracic curve** is a **primary curve**, meaning it is present at birth. - This **kyphotic curve** is convex posteriorly and accommodates the thoracic organs. *Sacral Vertebral Canal* - The **sacral curve** is another **primary curve**, also present at birth. - It is a **kyphotic curve**, convex posteriorly, and contributes to the pelvic basin's shape.

Q: After a 26-year-old man's car was sideswiped by a large truck, he is brought to the emergency department with multiple fractures of the transverse processes of the cervical and upper thoracic vertebrae. Which of the following muscles might be affected?

Levator scapulae. ***Levator scapulae*** - The **levator scapulae** muscle originates from the posterior tubercles of the transverse processes of cervical vertebrae C1-C4. - Fractures to these **transverse processes** could directly impact the attachment and function of the levator scapulae. *Serratus Posterior Superior* - The **serratus posterior superior** originates from the nuchal ligament and spinous processes of C7-T3, inserting onto ribs 2-5 - Its origin is primarily from the **spinous processes**, not the transverse processes, of the cervical and upper thoracic vertebrae. *Rhomboid major* - The **rhomboid major** muscle originates from the spinous processes of T2-T5, inserting into the medial border of the scapula. - Its origins are from the **spinous processes** of the upper thoracic vertebrae, not the transverse processes. *Trapezius* - The **trapezius** is a large muscle with a broad origin from the external occipital protuberance, nuchal ligament, and spinous processes of C7-T12. - While it covers a large area, its attachments are primarily to the **occiput** and **spinous processes**, not the transverse processes of the cervical and upper thoracic vertebrae.

Q: During a routine physical examination a 65-year-old male patient is tested for ease and flexibility of the movements of his lumbar region. Which of the following movements is most characteristic of the intervertebral joints in the lumbar region?

Lateral flexion. ***Lateral flexion*** - **Lateral flexion** (side bending) is the most characteristic movement of the lumbar spine among the given options. - This movement is primarily facilitated by the **frontal plane orientation of the facet joints** in the lumbar region. - The lumbar spine allows approximately **20-30 degrees of lateral flexion** to each side. - The structure of the intervertebral discs and facet joint orientation in the lumbar region particularly favor this movement. *Rotation* - **Rotation** is the LEAST characteristic movement of the lumbar spine. - The lumbar facet joints are oriented in the **sagittal plane**, which significantly **restricts rotational movement**. - The lumbar spine allows only about **5 degrees of rotation**, much less than the thoracic or cervical regions. - Most trunk rotation actually occurs at the thoracic spine, not the lumbar region. *Circumduction* - **Circumduction** is a combined, sequential movement (flexion → lateral flexion → extension → lateral flexion) typically seen in ball-and-socket joints. - While the spine can perform these individual movements, circumduction is not considered a characteristic or distinct movement of intervertebral joints. - This term is more applicable to joints like the shoulder and hip. *Extension* - **Extension** (backward bending) is certainly possible and important in the lumbar spine. - However, it is not the MOST characteristic movement—the lumbar spine allows approximately **20-25 degrees of extension**. [1] - Flexion (forward bending, 40-60 degrees) and lateral flexion are more prominent movements in the lumbar region during functional activities.

Q: 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?

Compression of the cauda equina. ***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**.

Q: What is the nerve supply of the shown muscle?

Dorsal scapular. ***Dorsal scapular*** - The image points to the **levator scapulae muscle**, which elevates and rotates the scapula. - The **dorsal scapular nerve** (C5 root, with contributions from C3-C4) innervates the levator scapulae, as well as the rhomboid major and minor muscles. - This nerve arises from the C5 root of the brachial plexus and pierces through the middle scalene muscle. - Clinically, injury to the dorsal scapular nerve can cause **medial scapular winging** and difficulty elevating the shoulder. *Suprascapular* - The suprascapular nerve (C5-C6) primarily innervates the **supraspinatus and infraspinatus muscles**, which are involved in rotator cuff function. - It does not supply the levator scapulae muscle. - This nerve passes through the suprascapular notch beneath the superior transverse scapular ligament. *Dorsal rami of C1* - The **dorsal ramus of C1** (suboccipital nerve) primarily innervates the muscles of the suboccipital triangle: rectus capitis posterior major and minor, obliquus capitis superior and inferior. - These nerves are involved in fine head and neck movements but do not innervate the levator scapulae. - The levator scapulae receives segmental innervation from C3-C4 cervical nerves directly, in addition to the dorsal scapular nerve. *Subscapular* - The subscapular nerves (upper and lower, from C5-C6) innervate the **subscapularis muscle**, which is part of the rotator cuff. - They also innervate the **teres major muscle**, but not the levator scapulae. - These are branches from the posterior cord of the brachial plexus.

Q: Shape of trapezius muscle is:

Triangular. ***Triangular*** - The **trapezius muscle** is a large, flat, **triangular muscle** extending over the posterior neck and upper thorax. - Each trapezius muscle has a **triangular shape** with the base along the vertebral column (from occipital protuberance to T12 vertebra) and the apex pointing laterally toward the shoulder (acromion and spine of scapula). - This triangular configuration is the standard anatomical description found in **Gray's Anatomy** and other authoritative anatomy texts. - The muscle has three parts: **descending (superior), transverse (middle), and ascending (inferior)** fibers, all converging toward the lateral shoulder. *Trapezium* - The name "trapezius" is derived from the **trapezoid/trapezium shape** formed when **both left and right trapezius muscles are viewed together** as a pair meeting at the midline. - However, the question asks about the shape of "trapezius muscle" (singular), which anatomically refers to the **individual muscle**, not the bilateral pair. - While the etymology relates to trapezium, the actual anatomical description of each muscle is **triangular**. *Quadrilateral* - This is a **general geometric term** for any four-sided polygon, which is too non-specific for anatomical description. - While technically a triangle is not a quadrilateral (it has three sides, not four), this option doesn't accurately capture the specific shape of the trapezius muscle. - Many muscles could loosely be called quadrilateral, making this term anatomically imprecise. *Quadrangular* - **Quadrangular** is synonymous with quadrilateral, referring to a four-sided figure. - This term is too broad and does not specifically describe the distinctive **three-sided (triangular)** shape of the individual trapezius muscle. - Not the standard anatomical terminology used for this muscle.

Question 1

All are pierced in Lumbar Puncture except:

Accepted Answer

Posterior longitudinal ligament

Answer

Interspinous Ligament

Answer

Ligamentum Flavum

Answer

Supraspinous ligament

Question 2

A 7-year-old female who is somewhat obese is brought to the emergency department because of a soft lump above the buttocks. Upon physical examination you note the lump is located just superior to the iliac crest unilaterally on the left side. The protrusion is deep to the skin and pliable to the touch. Which of the following is the most probable diagnosis?

Accepted Answer

Herniation at the lumbar triangle (of Petit)

Answer

Indirect inguinal hernia

Answer

Tumor of the external abdominal oblique muscle

Answer

Direct inguinal hernia

Question 3

All are TRUE about intervertebral disc, EXCEPT:

Accepted Answer

Rich vascular supply

Answer

Prolapse is most common in lumbosacral region

Answer

Nucleus pulposus is a remnant of notochord

Answer

Annulus fibrosus is made up of fibrocartilage

Question 4

Membrana tectoria is continuation of:

Accepted Answer

Posterior longitudinal ligament

Answer

Anterior atlanto-occipital membrane

Answer

Anterior longitudinal ligament

Answer

Posterior atlanto-occipital membrane

Question 5

Which of the following parts of the vertebral canal shows the first secondary curve to develop?

Accepted Answer

Cervical Vertebral Canal

Answer

Lumbar Vertebral Canal

Answer

Thoracic Vertebral Canal

Answer

Sacral Vertebral Canal

Question 6

After a 26-year-old man's car was sideswiped by a large truck, he is brought to the emergency department with multiple fractures of the transverse processes of the cervical and upper thoracic vertebrae. Which of the following muscles might be affected?

Accepted Answer

Levator scapulae

Answer

Serratus Posterior Superior

Answer

Rhomboid major

Answer

Trapezius

Question 7

During a routine physical examination a 65-year-old male patient is tested for ease and flexibility of the movements of his lumbar region. Which of the following movements is most characteristic of the intervertebral joints in the lumbar region?

Accepted Answer

Lateral flexion

Answer

Rotation

Answer

Circumduction

Answer

Extension

Question 8

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?

Accepted Answer

Compression of the cauda equina

Answer

Compression of the conus medullaris

Answer

Rupture of the anterior spinal ligament

Answer

Compression of the spinal cord at the level of L3

Question 9

What is the nerve supply of the shown muscle?

Accepted Answer

Dorsal scapular

Answer

Suprascapular

Answer

Dorsal rami of C1

Answer

Subscapular

Question 10

Shape of trapezius muscle is:

Accepted Answer

Triangular

Answer

Quadrilateral

Answer

Quadrangular

Answer

Trapezium

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