Spine Disorders Practice Questions

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: A patient presents in the emergency with a cervical spine fracture. What is the first priority in management?

Immobilize the cervical spine. **Explanation:** In any suspected cervical spine injury, the primary goal is to **prevent secondary spinal cord injury**. Any movement of an unstable fracture can lead to permanent neurological deficit or respiratory arrest due to phrenic nerve involvement (C3-C5). **Why Option D is Correct:** Immobilization is the "zero-priority" step in trauma management. Before performing any maneuvers or transporting the patient, the cervical spine must be stabilized using a rigid cervical collar, sandbags, or manual in-line stabilization (MILS). This ensures that the spinal cord is protected during subsequent life-saving interventions. **Analysis of Incorrect Options:** * **Option A:** Shifting the patient side-to-side is strictly contraindicated. This "log-rolling" should only be done by a trained team once the spine is stabilized to check for back injuries. * **Option B:** While imaging is essential for diagnosis, "Radiology never precedes Resuscitation/Stabilization." You must stabilize the patient before moving them to the X-ray suite. * **Option C:** While "Airway" is the 'A' in the ABCDE protocol, in trauma, it is always **"Airway with Cervical Spine Protection."** Blind intubation without stabilization can cause hyperextension of the neck, potentially transecting the cord. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Clearance:** A clinically conscious, sober, and asymptomatic patient (NEXUS criteria). * **Best Initial Imaging:** Lateral X-ray (must visualize up to the C7-T1 junction). * **Investigation of Choice (IOC):** MRI for soft tissue/cord injury; CT for bony anatomy. * **Management Tip:** If intubation is required, use **Manual In-Line Stabilization (MILS)** rather than a cervical collar to allow better visualization of the vocal cords while preventing neck extension.

Q: What is the probable diagnosis in a patient presenting with bilious vomiting, who is currently in a spinal POP cast?

Duodenal obstruction. **Explanation:** The patient is presenting with **Cast Syndrome** (also known as Superior Mesenteric Artery Syndrome). This occurs when a tight spinal POP (Plaster of Paris) cast, often used for scoliosis or spinal fractures, causes hyperextension of the spine. This position narrows the angle between the **Superior Mesenteric Artery (SMA)** and the **Aorta**, leading to compression of the **third part of the duodenum** which lies between them. The resulting mechanical obstruction leads to bilious vomiting, abdominal distension, and pain. **Analysis of Options:** * **B. Duodenal Obstruction (Correct):** This is the hallmark of Cast Syndrome. The compression of the duodenum by the SMA is the direct cause of the symptoms. * **A. Acute dilation of the stomach:** While this can occur secondary to duodenal obstruction (as the stomach cannot empty), it is a consequence rather than the primary diagnosis. * **C. Peritonitis:** This presents with guarding, rigidity, and fever. While a late complication of untreated obstruction could be perforation, it is not the primary diagnosis in a stable patient in a cast. * **D. Acute pancreatitis:** While it causes vomiting and pain, it is not specifically associated with spinal casting or mechanical compression by the SMA. **NEET-PG High-Yield Pearls:** * **Anatomical Site:** The 3rd part of the duodenum is compressed. * **Predisposing Factors:** Rapid weight loss (loss of mesenteric fat pad), spinal surgery, or application of a body cast (hip spica or body jacket). * **Management:** Immediate removal/splitting of the cast, nasogastric decompression, and placing the patient in the **left lateral decubitus or prone position** to open the SMA angle.

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 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.

Q: Disc herniation between L4 and L5 involves which nerve root?

L5. In the lumbar spine, the nerve roots exit the spinal canal **below** their corresponding vertebrae (e.g., the L4 nerve root exits through the L4-L5 neural foramen). However, due to the anatomy of the lumbar disc space, a **posterolateral disc herniation** (the most common type) typically affects the **traversing nerve root** rather than the exiting one. ### 1. Why L5 is Correct At the **L4-L5 level**, the L4 nerve root has already exited the canal above the disc. The **L5 nerve root** is currently traversing the L4-L5 disc space to reach its exit point below the L5 vertebra. Therefore, a standard posterolateral herniation at L4-L5 compresses the **L5 nerve root**. ### 2. Why Other Options are Incorrect * **L2 & L3 (Options A & B):** These roots exit at much higher levels (L2-L3 and L3-L4 respectively). They would only be involved in herniations at those specific higher levels. * **L4 (Option C):** While the L4 root is anatomically near the L4-L5 disc, it exits via the superior portion of the foramen. It is usually only compressed by a **far lateral (extraforaminal) disc herniation**, which is much less common than a posterolateral one. ### 3. Clinical Pearls for NEET-PG * **The "N+1" Rule:** In the lumbar spine, a posterolateral disc herniation at level **L(X)-L(Y)** affects the **L(Y)** nerve root. * **Cervical Spine Exception:** In the cervical spine, the nerve roots exit **above** the corresponding vertebrae. A C5-C6 herniation affects the **C6** root. * **L5 Root Findings:** Compression leads to weakness in **Great Toe Extension (EHL)** and foot dorsiflexion, with sensory loss over the first dorsal web space. * **Schmorl’s Node:** Protrusion of the nucleus pulposus into the vertebral body (vertical herniation).

Question 1

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 2

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 3

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 4

A patient presents in the emergency with a cervical spine fracture. What is the first priority in management?

Accepted Answer

Immobilize the cervical spine

Answer

Locate the fracture by shifting the patient side to side

Answer

Obtain an X-ray of the spine

Answer

Clear the airway and intubate the patient

Question 5

What is the probable diagnosis in a patient presenting with bilious vomiting, who is currently in a spinal POP cast?

Accepted Answer

Duodenal obstruction

Answer

Acute dilation of the stomach

Answer

Peritonitis

Answer

Acute pancreatitis

Question 6

Compression of which of the following structures results in pseudoclaudication?

Accepted Answer

Cauda equina

Answer

Femoral artery

Answer

Femoral nerve

Answer

Popliteal artery

Question 7

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 8

Which joint is typically NOT involved in osteoarthritis?

Accepted Answer

Metacarpophalangeal joint

Answer

Distal interphalangeal joints

Answer

Knee joint

Answer

Proximal interphalangeal joint

Question 9

Lumbar canal stenosis typically presents as?

Accepted Answer

Claudication

Answer

Scoliotic deformity

Answer

Kyphotic deformity

Answer

Radiculopathy

Question 10

Disc herniation between L4 and L5 involves which nerve root?

Accepted Answer

L5

Answer

L2

Answer

L3

Answer

L4

Spine Disorders — MCQs

Spine Disorders — MCQs

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