Spine Disorders Practice Questions

Q: All of the following are radiological features of tuberculosis of the spine except?

Marked osteoblastic response. **Explanation:** Tuberculosis of the spine (Pott’s disease) is primarily a **destructive (osteolytic)** process. Understanding the pathophysiology of TB is key to answering this question. **1. Why "Marked osteoblastic response" is the correct answer:** TB is characterized by a lack of proteolytic enzymes, leading to slow bone destruction. Unlike pyogenic (bacterial) osteomyelitis, which often shows significant reactive bone formation (sclerosis/osteoblastic response), TB is predominantly **osteolytic**. Any osteoblastic response or sclerosis in TB is usually minimal and occurs only during the late healing phase. Therefore, a "marked" response is not a feature of active TB. **2. Analysis of incorrect options:** * **Large paraspinal abscess (Option A):** This is a hallmark of TB. Due to the slow progression, the infection often spreads under the longitudinal ligaments, forming large "cold abscesses" (fusiform or psoas abscesses). * **Marked collapse of vertebra (Option B):** As the bone is progressively destroyed and weakened (osteolysis), the weight of the body causes the vertebral body to collapse, often leading to **wedging** and the characteristic **Gibbus deformity**. * **Decreased joint space (Option D):** TB typically starts in the paradiscal region. It destroys the subchondral bone plates, leading to the narrowing and eventual loss of the intervertebral disc space. **Clinical Pearls for NEET-PG:** * **Earliest sign:** Rarefaction (osteopenia) of the vertebral body. * **Most common site:** Lower thoracic and upper lumbar vertebrae. * **Paradiscal type:** The most common pattern of involvement. * **Skip lesions:** TB can involve non-contiguous vertebrae (seen in ~10-15% of cases). * **Imaging Gold Standard:** MRI is the investigation of choice for early diagnosis and evaluating cord compression.

Q: What is the most common site for spinal trauma?

Cervical. **Explanation:** The **Cervical spine** is the most common site for spinal trauma due to its unique anatomical and functional characteristics. It is the most mobile segment of the vertebral column, supporting the weight of the head while lacking the structural stability provided by the rib cage (as seen in the thoracic spine). The high range of motion, combined with its relative lack of surrounding muscular protection compared to the lumbar region, makes it highly susceptible to acceleration-deceleration injuries (whiplash), falls, and high-velocity motor vehicle accidents. Within the cervical spine, **C2** is the most common site of fracture, while **C5-C6** is the most common site for subluxation. **Analysis of Incorrect Options:** * **Thoracic Spine:** This is the least mobile segment due to the stabilizing effect of the rib cage and the coronal orientation of the facet joints. It requires significant force to fracture, often associated with high-energy trauma. * **Lumbar Spine:** While the **Thoracolumbar junction (T12-L1)** is the most common site for *osteoporotic* or *wedge compression* fractures, the cervical spine remains the most frequent site for overall traumatic injuries. * **Sacrum:** Fractures here are relatively rare and usually occur in the context of high-energy pelvic ring disruptions or as insufficiency fractures in elderly patients. **NEET-PG High-Yield Pearls:** * **Most common site of spinal injury:** Cervical spine (specifically C2 for fractures, C5-C6 for cord injury). * **Most common site for Thoracolumbar fractures:** T12-L1 (transition zone from rigid thoracic to mobile lumbar). * **Jefferson Fracture:** Burst fracture of C1 (Atlas). * **Hangman’s Fracture:** Traumatic spondylolisthesis of C2 (Axis). * **Chance Fracture:** Horizontal seatbelt injury, most common at L1-L2.

Q: What is the treatment of choice for a patient with D7-D8 Pott's disease presenting with paraplegia?

Anti-Koch's treatment (AKT). In Pott’s disease (Spinal Tuberculosis), the primary treatment modality is medical management. **Why Anti-Koch’s Treatment (AKT) is the Correct Answer:** The standard of care for spinal TB, even in the presence of neurological deficits like paraplegia, is the initiation of **Anti-Koch’s Treatment (AKT)**. In most cases of "early-onset" paraplegia (caused by inflammatory edema, granulation tissue, or abscess), the neurological symptoms resolve significantly with chemotherapy alone. Surgery is generally reserved for patients who fail to respond to AKT or have specific mechanical indications. **Why Other Options are Incorrect:** * **Laminectomy:** This is generally **contraindicated** in Pott’s disease. Since TB primarily affects the vertebral bodies (anterior column), a laminectomy removes the only remaining stable posterior elements, leading to spinal instability and worsening kyphosis. * **Anterior/Posterior Decompression:** These are surgical interventions. While anterior decompression (e.g., Hong Kong operation) is effective for clearing necrotic bone and pus, it is **not the first-line** treatment of choice. Surgery is indicated only if there is no neurological improvement after 3–4 weeks of AKT, rapid worsening of paraplegia, or severe spinal instability. **Clinical Pearls for NEET-PG:** * **Most common site:** Lower Thoracic (Dorsal) spine. * **Earliest sign on X-ray:** Reduction in disc space (due to destruction of adjacent vertebral endplates). * **Cold Abscess:** In the dorsal spine, it presents as a **"Bird’s Nest" appearance** (paravertebral shadow) on X-ray. * **Tuli’s Classification:** Used to stage neurological deficit in spinal TB. * **Gold Standard Investigation:** MRI (shows marrow edema and soft tissue involvement earliest).

Q: Milwaukee brace is used for the management of which condition?

Scoliosis. **Explanation:** The **Milwaukee brace** (Cervico-Thoraco-Lumbo-Sacral Orthosis or CTLSO) is a classic active corrective orthosis primarily used for the non-operative management of **Scoliosis**. It is specifically indicated for curves with an apex above T8. The brace works on the principle of longitudinal traction and lateral pressure, utilizing a neck ring, pelvic mold, and upright bars to provide corrective forces that prevent curve progression during skeletal growth. **Analysis of Options:** * **Scoliosis (Correct):** It is the gold standard for high thoracic curves. It aims to maintain the curve until skeletal maturity (Risser sign 4 or 5). * **Kyphosis:** While the Milwaukee brace can be modified for Scheuermann’s kyphosis, its primary and most classic association in orthopedic examinations is Scoliosis. * **Spondylolisthesis:** This condition (forward slippage of vertebrae) is typically managed with a **Boston brace** (TLSO) or a lumbosacral corset to limit extension, not a Milwaukee brace. * **Developmental Dysplasia of the Hip (DDH):** DDH is managed using dynamic splints like the **Pavlik harness** (for infants <6 months) or a Von Rosen splint. **High-Yield Clinical Pearls for NEET-PG:** * **Boston Brace:** A Thoraco-Lumbo-Sacral Orthosis (TLSO) used for scoliosis with an apex below T8 (more cosmetically acceptable as it lacks the neck ring). * **Charleston Bending Brace:** A "night-time only" brace used for scoliosis. * **Indication for Bracing:** Generally indicated for curves between **20° and 40°** (Cobb’s angle) in a growing child. * **Indication for Surgery:** Usually required when the Cobb’s angle exceeds **40°–45°**.

Q: Which of the following spine deformities is being evaluated?

Scoliosis. ***Scoliosis*** - **Lateral curvature** of the spine visible on posterior view, often with **rotational component** causing rib prominence - Diagnosed using **Cobb angle measurement** on X-ray and **Adam's forward bend test** to assess rib hump *Kyphosis* - **Anterior flexion** or **forward curvature** of the spine, typically in the thoracic region, creating a **hunched back** appearance - Best visualized on **lateral view** rather than posterior view, unlike the lateral deviation seen here *Gibbus* - **Sharp angular kyphosis** caused by vertebral collapse from **tuberculosis** or **fracture**, creating a distinct angular prominence - Presents as a **localized hump** rather than the smooth lateral curvature pattern observed *Lordosis* - **Exaggerated inward curvature** of the lumbar spine creating increased **lumbar concavity** - Appears as **swayback posture** on lateral view, not as lateral spinal deviation seen in this evaluation

Q: Spondylolysis is more common in which anatomical location?

Pars interarticularis. **Explanation:** **Spondylolysis** refers to a bony defect or stress fracture in the **pars interarticularis** of the vertebral arch. The pars interarticularis is the specific segment of bone between the superior and inferior articular processes of a vertebra. This area is anatomically vulnerable to repetitive mechanical stress, particularly hyperextension, which leads to micro-fractures. It most commonly occurs at the **L5 level (90%)**, followed by L4. **Analysis of Options:** * **Pars interarticularis (Correct):** This is the classic site of the defect. On an oblique X-ray of the lumbar spine, this defect appears as a "break in the neck" of the **Scotty Dog sign**. * **Intervertebral disc & Annulus fibrosus (Incorrect):** These are soft tissue components of the spine. While they are involved in disc herniations (prolapse), spondylolysis is strictly a bony pathology. * **Anterior pars (Incorrect):** This is not a standard anatomical term used to describe the site of this fracture. The defect is specifically localized to the posterior elements of the vertebra. **Clinical Pearls for NEET-PG:** 1. **Spondylolisthesis:** If the bilateral pars defect leads to the forward slipping of one vertebra over another, the condition is termed Spondylolisthesis. 2. **Most Common Site:** L5 is the most common site for spondylolysis; however, for **degenerative** spondylolisthesis, **L4 over L5** is more common. 3. **Imaging:** The **Oblique view** X-ray is best for visualizing the "Scotty Dog," but **CT scan** is the gold standard for diagnosing the bony defect. 4. **Population:** It is frequently seen in young athletes involved in gymnastics, diving, or fast bowling (cricket) due to repeated lumbar hyperextension.

Q: In a case of tuberculosis of the thoracic spine, what is the earliest sign of cord compression?

Extensor plantar response. In Tuberculosis of the spine (Pott’s disease), cord compression typically occurs due to an abscess, granulation tissue, or bony sequestration. Because the thoracic spine is the most common site for Pott's paraplegia, the compression affects the **Upper Motor Neuron (UMN)** pathways. ### Why "Extensor Plantar Response" is Correct The earliest clinical manifestation of spinal cord compression is the loss of inhibitory control from the corticospinal tracts. This leads to **Babinski’s sign (Extensor Plantar Response)**. It precedes subjective motor weakness or sensory changes because the long tracts are highly sensitive to early mechanical pressure or ischemia. At this stage, the patient may be asymptomatic or have only "clumsy" gaits, but the physical exam will reveal the extensor response. ### Why Other Options are Incorrect * **Motor Weakness:** This is usually the first *symptom* the patient notices (heaviness or dragging of feet), but it occurs after the reflex changes are already present. * **Sensory Loss:** Sensory fibers are generally more resistant to pressure than motor fibers. Sensory loss (numbness/paresthesia) typically appears after motor deficits. * **Bladder Dysfunction:** This is a **late sign** of cord compression. Its presence indicates significant, advanced compression and carries a poorer prognosis for recovery. ### High-Yield Clinical Pearls for NEET-PG * **Sequence of involvement:** Reflex changes (Extensor plantar) → Motor weakness → Sensory loss → Bladder/Bowel involvement. * **Most common site of Pott's Spine:** Lower Thoracic / Dorso-lumbar junction. * **Earliest Radiological Sign:** Diminution/narrowing of the disc space (due to destruction of the subchondral bone). * **Cold Abscess in Thoracic Spine:** Appears as a "Bird's Nest" or fusiform shadow on X-ray.

Q: In which of the following conditions does pseudoclaudication occur?

Lumbar canal stenosis. **Explanation:** **Lumbar Canal Stenosis (LCS)** is the correct answer because it is the classic cause of **pseudoclaudication** (also known as neurogenic claudication). This condition occurs due to the narrowing of the spinal canal, which compresses the nerve roots of the cauda equina. During walking or standing, the lumbar spine undergoes extension, further narrowing the canal and increasing venous congestion around the nerve roots. This leads to ischemia of the nerves, manifesting as pain, heaviness, or paresthesia in the lower limbs. **Why the other options are incorrect:** * **Options A and B (Femoral and Popliteal artery stenosis):** These cause **true vascular claudication**. While the symptoms (leg pain on walking) are similar, the underlying mechanism is arterial insufficiency (decreased blood supply to muscles) rather than nerve compression. * **Option D (Radial artery stenosis):** This affects the upper limb and would not present with claudication symptoms in the legs. **Clinical Pearls for NEET-PG:** * **The "Shopping Cart Sign":** Patients with LCS feel relief when leaning forward (flexion), as this increases the functional diameter of the spinal canal. This distinguishes it from vascular claudication. * **Bicycle Test of van Gelderen:** Patients with neurogenic claudication can cycle longer than they can walk because the spine is in a flexed position while cycling. * **Pulses:** In pseudoclaudication, peripheral pulses (Dorsalis pedis/Posterior tibial) are **normal**, whereas they are absent or feeble in vascular claudication. * **Investigation of Choice:** MRI Spine is the gold standard for diagnosing Lumbar Canal Stenosis.

Question 1

All of the following are radiological features of tuberculosis of the spine except?

Accepted Answer

Marked osteoblastic response

Answer

Large paraspinal abscess

Answer

Marked collapse of vertebra

Answer

Decreased joint space

Question 2

What is the most common site for spinal trauma?

Accepted Answer

Cervical

Answer

Thoracic

Answer

Lumbar

Answer

Sacrum

Question 3

A young woman presented with mild quadriparesis following an accident. Her lateral X-ray of the cervical spine revealed a C5-C6 fracture-dislocation. What is the most appropriate line of management?

Accepted Answer

Cervical traction followed by instrumented fixation

Answer

Immediate anterior decompression

Answer

Hard cervical collar and bed rest

Answer

Cervical laminectomy

Question 4

What is the treatment of choice for a patient with D7-D8 Pott's disease presenting with paraplegia?

Accepted Answer

Anti-Koch's treatment (AKT)

Answer

Anterior decompression

Answer

Laminectomy

Answer

Posterior decompression

Question 5

Milwaukee brace is used for the management of which condition?

Accepted Answer

Scoliosis

Answer

Kyphosis

Answer

Spondylolisthesis

Answer

Developmental dysplasia of the hip

Question 6

A 25-year-old male presents with a three-month history of lower back pain, following a fall. He reports mild weakness in both lower limbs but can walk without support. He has approximately 30% sensory loss and exhibits bladder symptoms. Physical examination reveals tenderness over D12-L1 vertebrae. X-ray shows paradiscal destruction of vertebrae, and MRI reveals destruction with indentation of the thecal sac. What is the most appropriate management?

Accepted Answer

Anti-tuberculosis treatment (ATT) and surgical decompression

Answer

Observation

Answer

Domiciliary anti-tuberculosis treatment (ATT)

Answer

Hospital admission and anti-tuberculosis treatment (ATT)

Question 7

Which of the following spine deformities is being evaluated?

Accepted Answer

Scoliosis

Answer

Kyphosis

Answer

Gibbus

Answer

Lordosis

Question 8

Spondylolysis is more common in which anatomical location?

Accepted Answer

Pars interarticularis

Answer

Intervertebral disc

Answer

Anterior pars

Answer

Annulus fibrosus

Question 9

In a case of tuberculosis of the thoracic spine, what is the earliest sign of cord compression?

Accepted Answer

Extensor plantar response

Answer

Bladder dysfunction

Answer

Motor weakness

Answer

Sensory loss

Question 10

In which of the following conditions does pseudoclaudication occur?

Accepted Answer

Lumbar canal stenosis

Answer

Femoral artery stenosis

Answer

Popliteal artery stenosis

Answer

Radial artery stenosis

Spine Disorders — MCQs

Spine Disorders — MCQs

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