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6. Spine MCQs

Practice Set 355 of 379

This practice set contains high-yield board review questions covering key concepts in 6. Spine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 7081

Topic: 6. Spine

Which of the following physical examination findings is most specific for nerve root compression in the lumbar spine?

. Paraspinal muscle spasm
. Reduced lumbar range of motion
. Pain with palpation over the spinous processes
. Motor weakness in a specific myotome
. Positive FABER test

Correct Answer & Explanation

. Motor weakness in a specific myotome

Explanation

Motor weakness in a specific myotome (e.g., L5 weakness affecting great toe extension or S1 weakness affecting plantarflexion) is a highly specific sign of nerve root compression (radiculopathy). Paraspinal muscle spasm, reduced lumbar range of motion, and localized tenderness are common findings in various musculoskeletal back conditions and are not specific for nerve root compression. A positive FABER (Flexion, Abduction, External Rotation) test suggests sacroiliac joint or hip pathology, not primarily nerve root compression.

Question 7082

Topic: 6. Spine

A 12-year-old gymnast presents with chronic low back pain that is worse with hyperextension activities. She denies any neurological symptoms. Radiographs are normal. What is the most appropriate next step in diagnosis?

. MRI of the lumbar spine
. CT scan of the lumbar spine
. Bone scan (SPECT/CT)
. Electromyography (EMG)
. Observe and restrict activity only

Correct Answer & Explanation

. Bone scan (SPECT/CT)

Explanation

In a young athlete with back pain exacerbated by hyperextension and normal radiographs, a stress fracture of the pars interarticularis (spondylolysis) should be strongly suspected. While plain radiographs are the initial step, early stress reactions or non-displaced fractures may not be visible. A SPECT (Single Photon Emission Computed Tomography) bone scan, often combined with CT, is highly sensitive for detecting active stress reactions or early spondylolysis. MRI is excellent for soft tissue, but early pars lesions can be missed if not specifically looked for. CT provides excellent bone detail and can visualize a pars defect. EMG is for nerve function, not bony injury. Observation alone without further diagnostic workup risks progression of the injury.

Question 7083

Topic: 6. Spine

A 50-year-old male with a history of prostate cancer presents with new-onset, severe low back pain that is constant, dull, and worse at night, not relieved by rest. He denies any recent trauma. Neurological examination is unremarkable. Which diagnostic test is most critical at this stage?

. Plain radiographs of the lumbar spine
. MRI of the lumbar spine with gadolinium
. CT scan of the abdomen and pelvis
. Bone density scan (DXA)
. Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP)

Correct Answer & Explanation

. MRI of the lumbar spine with gadolinium

Explanation

Given the patient's history of prostate cancer and new-onset, constant, nocturnal back pain (a red flag for malignancy), metastatic disease to the spine is a primary concern. MRI of the lumbar spine with gadolinium is the most sensitive and specific imaging modality for detecting spinal metastases, epidural cord compression, and other soft tissue pathology related to cancer. Plain radiographs might show osteolytic or osteoblastic lesions but can be normal in early metastatic disease. A CT scan of the abdomen/pelvis would assess primary tumor status but is less detailed for the spine itself. Bone density scan is for osteoporosis. ESR/CRP are inflammatory markers but less specific than MRI for identifying the source of pain in this context.

Question 7084

Topic: 6. Spine

A patient presents with acute onset low back pain and left leg pain that started after lifting a heavy object. The pain radiates down the posterior aspect of the left thigh and calf to the foot. On examination, there is decreased sensation in the lateral aspect of the left foot and weakness in left plantarflexion. The ankle jerk reflex is absent on the left. Which level of disc herniation is most likely responsible?

. L3-L4
. L4-L5
. L5-S1
. S1-S2
. L2-L3

Correct Answer & Explanation

. L5-S1

Explanation

This constellation of symptoms is classic for an L5-S1 disc herniation compressing the S1 nerve root. S1 radiculopathy typically presents with pain radiating down the posterior leg, sensory loss in the lateral foot/plantar aspect, weakness in plantarflexion (gastrocnemius/soleus), and an absent or diminished ankle jerk reflex. L4-L5 disc herniation typically affects the L5 nerve root, causing pain radiating to the dorsum of the foot, weakness in great toe extension/ankle dorsiflexion, and no reflex changes (though the medial hamstring reflex can be affected). L3-L4 affects the L4 nerve root, causing quadriceps weakness and diminished patellar reflex.

Question 7085

Topic: 6. Spine
Which of the following is NOT typically considered a 'red flag' symptom warranting immediate investigation in a patient presenting with back pain?
. Fever and chills
. Progressive neurological deficit
. Acute onset of back pain in a patient over 50 years old
. Unexplained weight loss
. History of IV drug use

Correct Answer & Explanation

. Acute onset of back pain in a patient over 50 years old

Explanation

Acute onset of back pain in a patient over 50 years old, while a 'red flag' that warrants careful consideration for conditions like compression fracture, malignancy, or AAA, does not necessarily require immediate investigation in the absence of other concerning symptoms. However, it is an important demographic factor that increases the index of suspicion for more serious pathology. Fever/chills (infection), progressive neurological deficit (spinal cord compression, cauda equina), unexplained weight loss (malignancy), and history of IV drug use (spinal infection) are all strong indicators for urgent workup.

Question 7086

Topic: 6. Spine

A 68-year-old male with a history of peripheral vascular disease presents with unilateral buttock and posterior thigh pain that is worse with walking and relieved by rest. He denies any low back pain. Physical examination is unremarkable, with normal neurological findings. What is the most important differential diagnosis to consider?

. Lumbar disc herniation
. Sacroiliac joint dysfunction
. Lumbar spinal stenosis
. Claudication due to peripheral arterial disease
. Piriformis syndrome

Correct Answer & Explanation

. Claudication due to peripheral arterial disease

Explanation

The patient's presentation of unilateral buttock and posterior thigh pain, worsening with walking and relieved by rest, with no low back pain or neurological findings on exam, is classic for vascular claudication due to peripheral arterial disease (PAD). This is a critical differential for neurogenic claudication (from spinal stenosis). While lumbar disc herniation or spinal stenosis could cause leg pain, the absence of back pain and presence of a vascular history makes PAD a prime suspect. Sacroiliac joint dysfunction typically causes localized buttock pain. Piriformis syndrome causes buttock pain with possible sciatica, but its claudication pattern is less typical. Differentiation often involves asking about the nature of the pain (cramping vs. numbness/tingling) and presence of peripheral pulses, ankle-brachial index, and potentially vascular ultrasound.

Question 7087

Topic: 6. Spine

A 35-year-old pregnant woman in her third trimester develops acute, severe low back pain radiating to her right buttock and posterior thigh. She denies any trauma or 'red flag' symptoms. Neurological examination is normal. What is the most appropriate initial imaging study, if any, to consider?

. MRI of the lumbar spine without contrast
. Plain radiographs of the lumbar spine
. CT scan of the lumbar spine
. Bone scan
. None, focus on conservative management

Correct Answer & Explanation

. MRI of the lumbar spine without contrast

Explanation

In pregnant patients with acute back pain and radicular symptoms, conservative management is usually the first line. However, if symptoms are severe and persistent, and especially if there's concern for disc herniation, MRI without gadolinium contrast is the imaging modality of choice. It provides excellent soft tissue detail (discs, nerves) and does not involve ionizing radiation, making it safe for the fetus. Plain radiographs and CT scans involve ionizing radiation and are generally avoided unless absolutely necessary. Bone scans are contraindicated in pregnancy. While many cases resolve with conservative management, severe acute pain may warrant imaging to rule out significant pathology that could impact delivery or require intervention, with MRI being the safest option.

Question 7088

Topic: 6. Spine

Which of the following describes the typical pain pattern associated with sacroiliac joint dysfunction?

. Midline low back pain radiating down the posterior leg to the foot
. Bilateral buttock and leg pain worsening with walking, improving with sitting
. Pain localized to the buttock, often unilateral, referred to the posterior thigh, exacerbated by prolonged sitting or standing on one leg
. Pain primarily in the groin and anterior thigh, worsened by hip rotation
. Severe, acute pain in the mid-thoracic region after a minor fall

Correct Answer & Explanation

. Pain localized to the buttock, often unilateral, referred to the posterior thigh, exacerbated by prolonged sitting or standing on one leg

Explanation

Sacroiliac joint (SIJ) dysfunction typically presents with pain localized to the buttock, often unilateral, which may refer to the posterior thigh, groin, or even the lower abdomen. It is commonly exacerbated by activities that stress the SI joint, such as prolonged sitting, standing on one leg, climbing stairs, or transitional movements (e.g., getting out of a car). Midline low back pain with posterior leg radiation is more suggestive of disc herniation. Bilateral leg pain with walking relief with sitting is neurogenic claudication from spinal stenosis. Groin/anterior thigh pain with hip rotation suggests hip pathology. Mid-thoracic pain after a fall suggests a vertebral compression fracture.

Question 7089

Topic: 6. Spine

A 25-year-old male presents with persistent low back pain for 6 months, worse in the morning and improving with activity. He also reports fatigue, stiffness, and occasional heel pain (enthesitis). Physical examination reveals limited lumbar flexion and tenderness over the sacroiliac joints. Which serological test would be most helpful in confirming the suspected diagnosis?

. Rheumatoid Factor (RF)
. Anti-nuclear Antibody (ANA)
. HLA-B27
. Anti-CCP antibody
. Uric acid level

Correct Answer & Explanation

. HLA-B27

Explanation

The patient's age, chronic inflammatory back pain (worse in morning, improves with activity), enthesitis (heel pain), and sacroiliac joint tenderness are classic features of ankylosing spondylitis, a seronegative spondyloarthropathy. HLA-B27 is a genetic marker strongly associated with ankylosing spondylitis (present in ~90% of Caucasians with the disease). Rheumatoid Factor (RF), Anti-nuclear Antibody (ANA), and Anti-CCP antibody are associated with rheumatoid arthritis and other autoimmune conditions, not typically spondyloarthropathies. Uric acid levels are relevant for gout. While HLA-B27 is not diagnostic on its own, it strongly supports the clinical suspicion in this context.

Question 7090

Topic: 6. Spine

A 75-year-old male with a history of recurrent urinary tract infections and recent low back pain develops fever, elevated ESR/CRP, and progressive paraparesis. MRI shows an epidural collection compressing the spinal cord at L1. What is the most appropriate next step in management?

. Long-term oral antibiotics
. Outpatient physical therapy
. Urgent surgical decompression and debridement
. Steroid injections
. Observation with close neurological monitoring

Correct Answer & Explanation

. Urgent surgical decompression and debridement

Explanation

This patient presents with a spinal epidural abscess, complicated by fever, elevated inflammatory markers, and progressive neurological deficit (paraparesis), indicating spinal cord compression. This is a medical and surgical emergency. Urgent surgical decompression and debridement, along with intravenous antibiotics, are critical to prevent irreversible neurological damage. Long-term oral antibiotics alone are insufficient for cord compression. Outpatient physical therapy or steroid injections are contraindicated. Observation risks permanent neurological loss.

Question 7091

Topic: 6. Spine

A patient undergoing physical therapy for chronic low back pain reports that their pain is now consistently worse when they sit for more than 15 minutes, but improves significantly when they stand and walk. Which of the following conditions is most consistent with this change in symptoms?

. Lumbar spinal stenosis
. Sacroiliac joint dysfunction
. Facet joint arthropathy
. Lumbar disc herniation
. Spondylolisthesis

Correct Answer & Explanation

. Lumbar disc herniation

Explanation

Pain that is consistently worse with sitting and improves with standing/walking is highly suggestive of lumbar disc herniation. Sitting increases intradiscal pressure and can exacerbate symptoms of disc prolapse by putting direct pressure on the nerve root. Standing and walking, conversely, can relieve pressure on the nerve root. Lumbar spinal stenosis typically presents with pain worse with standing/walking and relieved by sitting. Sacroiliac joint dysfunction often worsens with prolonged sitting but has different relief mechanisms. Facet arthropathy pain is typically worse with extension. Spondylolisthesis can cause either, depending on the degree of stenosis or instability.

Question 7092

Topic: Thoracolumbar Spine & Deformity

Which type of spondylolisthesis is most commonly associated with a pars interarticularis defect?

. Degenerative spondylolisthesis
. Traumatic spondylolisthesis
. Isthmic spondylolisthesis
. Pathologic spondylolisthesis
. Dysplastic spondylolisthesis

Correct Answer & Explanation

. Isthmic spondylolisthesis

Explanation

Isthmic spondylolisthesis (also known as spondylolytic spondylolisthesis) is caused by a defect in the pars interarticularis, often due to a stress fracture. This is the most common type in younger individuals and athletes. Degenerative spondylolisthesis results from facet joint arthritis and disc degeneration, typically occurring in older adults without a pars defect. Traumatic spondylolisthesis is due to acute fracture of other parts of the vertebra. Pathologic spondylolisthesis is due to bone disease (e.g., tumor, infection). Dysplastic spondylolisthesis is congenital, characterized by malformation of the superior sacral or inferior L5 facets.

Question 7093

Topic: 6. Spine

When evaluating a patient with suspected lumbar disc herniation, which of the following physical examination maneuvers would be most helpful in confirming nerve root irritation?

. Schober's test
. Patrick's test (FABER)
. Femoral nerve stretch test
. Single-leg hyperextension test (Stork test)
. Compression/distraction of the lumbar spine

Correct Answer & Explanation

. Femoral nerve stretch test

Explanation

The femoral nerve stretch test (also known as the prone knee bend test) is specifically designed to stretch the femoral nerve (L2, L3, L4 nerve roots). A positive test, eliciting anterior thigh pain, is indicative of upper lumbar disc herniation or other anterior nerve root compression. Schober's test assesses lumbar flexion, relevant for inflammatory back pain. Patrick's test (FABER) assesses sacroiliac joint or hip pathology. The Stork test assesses pars interarticularis stress fracture. Compression/distraction is less specific for nerve root irritation, though distraction can temporarily relieve pressure.

Question 7094

Topic: 6. Spine

A 58-year-old female presents with persistent low back pain. She has a history of breast cancer treated with mastectomy and chemotherapy 5 years ago. Her pain is deep, aching, and not relieved by rest. On examination, she has localized tenderness over the L3 spinous process. Initial plain radiographs are reported as normal. What is the most appropriate next diagnostic step?

. Prescribe NSAIDs and observe
. Refer for psychological evaluation
. Order an MRI of the lumbar spine with contrast
. Perform a diagnostic epidural steroid injection
. Repeat plain radiographs in 6 weeks

Correct Answer & Explanation

. Order an MRI of the lumbar spine with contrast

Explanation

Given the patient's history of breast cancer and new-onset, persistent, non-mechanical back pain (constant, not relieved by rest), metastatic disease to the spine is a significant concern, even with normal initial plain radiographs. Breast cancer commonly metastasizes to bone. MRI of the lumbar spine with contrast is the most sensitive and specific imaging modality to detect spinal metastases, even when radiographs are normal, and can identify early epidural involvement. Delaying diagnosis can lead to neurological compromise. NSAIDs and observation are insufficient for a red flag presentation. Psychological evaluation is premature. Epidural steroid injections are therapeutic for radiculopathy, not diagnostic for malignancy. Repeating plain films would likely miss early pathology.

Question 7095

Topic: 6. Spine

What is the most common spinal level for symptomatic lumbar disc herniation?

. L2-L3
. L3-L4
. L4-L5
. L5-S1
. T12-L1

Correct Answer & Explanation

. L5-S1

Explanation

The L4-L5 and L5-S1 spinal levels are the most common sites for symptomatic lumbar disc herniation. This is due to the biomechanical stresses placed on these segments, being the junction between mobile lumbar spine and the relatively fixed sacrum, and bearing significant weight. The L5-S1 level is slightly more common than L4-L5. Herniations at higher lumbar levels (L2-L3, L3-L4) are less frequent. T12-L1 herniations are rare.

Question 7096

Topic: 6. Spine

A 42-year-old male presents with acute, severe low back pain after a fall. He reports feeling a 'pop' in his back. Examination reveals tenderness to palpation directly over the spinous process of L1. He has no neurological deficits. Which imaging modality is most appropriate to rule out a fracture?

. MRI of the lumbar spine
. CT scan of the lumbar spine
. Plain radiographs (AP and lateral) of the lumbar spine
. Bone scan
. Ultrasound of the lumbar spine

Correct Answer & Explanation

. Plain radiographs (AP and lateral) of the lumbar spine

Explanation

In the setting of acute back pain following trauma with localized spinous process tenderness, a vertebral fracture is a primary concern. Plain radiographs (AP and lateral views) are the initial imaging modality of choice to screen for fractures and assess vertebral alignment. If radiographs are inconclusive or if a complex fracture is suspected, a CT scan would be the next step for better bony detail. MRI is excellent for soft tissue (disc, spinal cord) but may not be the first choice for acute bony trauma, especially if CT is readily available and the primary concern is bone integrity. Bone scan detects metabolic activity, not ideal for acute fracture visualization. Ultrasound has no role in assessing vertebral fractures.

Question 7097

Topic: 6. Spine

A 62-year-old woman presents with low back pain and bilateral leg pain, worse when walking downhill, and improving when walking uphill or cycling. This pattern is characteristic of which condition?

. Lumbar disc herniation
. Vascular claudication
. Spinal epidural abscess
. Lumbar spinal stenosis
. Sacroiliac joint dysfunction

Correct Answer & Explanation

. Lumbar spinal stenosis

Explanation

The symptom pattern of pain worsening with walking downhill (which causes slight lumbar extension) and improving with walking uphill or cycling (which causes slight lumbar flexion) is a classic presentation of neurogenic claudication due to lumbar spinal stenosis. Lumbar extension narrows the spinal canal, while flexion widens it, relieving pressure on the neural elements. Lumbar disc herniation symptoms are often worse with sitting. Vascular claudication would be worse with any uphill/downhill walking and relieved purely by rest, not by positional changes. Spinal epidural abscess would present with systemic symptoms and rapid neurological deterioration. Sacroiliac joint dysfunction has a different pain pattern.

Question 7098

Topic: 6. Spine

Which finding on physical examination is most suggestive of an acute lumbar disc herniation with nerve root compression?

. Tenderness over the sacroiliac joint
. Limited lumbar flexion due to pain
. Positive straight leg raise test below 60 degrees causing radicular pain
. Hyper-reflexia in the lower extremities
. Widespread, non-dermatomal sensory loss

Correct Answer & Explanation

. Positive straight leg raise test below 60 degrees causing radicular pain

Explanation

A positive straight leg raise (SLR) test, eliciting radicular pain (pain radiating below the knee) when the leg is passively raised below 60 degrees, is the most sensitive and specific physical finding for a lumbar disc herniation compressing a lower lumbar nerve root (L5 or S1). Tenderness over the SI joint suggests SIJ dysfunction. Limited lumbar flexion is common in many back pain conditions. Hyper-reflexia suggests an upper motor neuron lesion (myelopathy), not typically a lumbar radiculopathy. Widespread, non-dermatomal sensory loss is indicative of a non-organic component to the pain.

Question 7099

Topic: 6. Spine

A 38-year-old patient with no significant past medical history presents with 3 days of severe low back pain and right leg pain, radiating to the lateral aspect of the foot. He has difficulty standing on his toes on the right. An MRI reveals a large L5-S1 disc herniation. He has no bladder/bowel dysfunction or saddle anesthesia. What is the most appropriate initial management?

. Emergency microdiscectomy
. Oral corticosteroids and bed rest for 1 week
. Conservative management including NSAIDs, activity modification, and early mobilization
. Transforaminal epidural steroid injection
. Long-term opioid prescription

Correct Answer & Explanation

. Conservative management including NSAIDs, activity modification, and early mobilization

Explanation

For most acute, symptomatic lumbar disc herniations without signs of cauda equina syndrome or progressive neurological deficit, conservative management is the initial treatment of choice. This includes NSAIDs, activity modification (avoiding aggravating activities but encouraging continued activity within pain limits), and early mobilization. The majority of disc herniations resolve or significantly improve with conservative care over 6-12 weeks. While an epidural steroid injection might be considered for persistent, severe radicular pain after a trial of oral medications, it is not always the immediate first step. Emergency microdiscectomy is reserved for cauda equina syndrome or severe, progressive neurological deficits refractory to conservative care. Bed rest is generally discouraged beyond 1-2 days. Long-term opioids are avoided due to addiction risk.

Question 7100

Topic: 6. Spine

Which condition is characterized by a forward slippage of one vertebral body over another, most commonly L5 over S1, due to bilateral pars interarticularis defects?

. Spinal stenosis
. Spondylosis
. Spondylitis
. Spondylolisthesis
. Scoliosis

Correct Answer & Explanation

. Spondylolisthesis

Explanation

Spondylolisthesis refers to the anterior (forward) slippage of one vertebral body relative to the one below it. When caused by bilateral pars interarticularis defects (spondylolysis), it is specifically termed isthmic spondylolisthesis, which most commonly occurs at L5-S1. Spinal stenosis is narrowing of the spinal canal. Spondylosis refers to degenerative changes of the spine. Spondylitis is inflammation of the vertebrae. Scoliosis is a lateral curvature of the spine.

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