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6. Spine MCQs

Practice Set 356 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 7101

Topic: 6. Spine

A 60-year-old male with a history of diabetes and hypertension presents with gradual onset low back pain and left leg weakness. He denies trauma. On examination, he has tenderness over the L4-L5 intervertebral space, weakness in left quadriceps strength, and a diminished left patellar reflex. Sensory exam reveals decreased sensation over the medial aspect of the left lower leg. What is the most likely diagnosis?

. L5 radiculopathy
. S1 radiculopathy
. L4 radiculopathy
. Femoral nerve neuropathy
. Spinal cord tumor

Correct Answer & Explanation

. L4 radiculopathy

Explanation

The constellation of symptoms: weakness in the quadriceps, diminished patellar reflex, and sensory loss over the medial aspect of the lower leg, is classic for an L4 radiculopathy. This is typically caused by a disc herniation at the L3-L4 level or spinal stenosis affecting the L4 nerve root. L5 radiculopathy affects great toe extension/ankle dorsiflexion and sensation on the dorsum of the foot. S1 radiculopathy affects plantarflexion, the ankle jerk reflex, and sensation on the lateral/plantar foot. Femoral nerve neuropathy would cause similar motor and sensory deficits but would usually be more distal or less associated with back pain, and less likely due to a spinal cause. A spinal cord tumor is a possibility for progressive weakness but the specific dermatomal and myotomal pattern points more directly to radiculopathy.

Question 7102

Topic: 6. Spine

Which finding is considered a 'soft' neurological sign in the context of back pain, requiring careful monitoring but not immediate surgical intervention unless progressive?

. Foot drop
. Bilateral leg weakness
. Saddle anesthesia
. Progressive worsening of a dermatomal sensory deficit
. New onset urinary retention

Correct Answer & Explanation

. Progressive worsening of a dermatomal sensory deficit

Explanation

A progressive worsening of a dermatomal sensory deficit, while a sign of nerve irritation/compression, is considered a 'soft' neurological sign. It warrants careful monitoring and re-evaluation but does not typically necessitate immediate surgical intervention unless it progresses rapidly or is associated with more severe motor or sphincter dysfunction. Foot drop (significant motor weakness), bilateral leg weakness, saddle anesthesia, and new onset urinary retention are all 'hard' neurological signs indicative of severe nerve compression (e.g., cauda equina syndrome or severe radiculopathy/myelopathy) and demand urgent evaluation and potentially immediate surgical intervention.

Question 7103

Topic: 6. Spine

A 22-year-old active duty military recruit develops persistent low back pain that is worse with physical activity and relieved by rest. He denies any neurological symptoms. Plain radiographs are normal. Given his occupation, which condition should be high on the differential diagnosis?

. Lumbar disc herniation
. Spinal epidural abscess
. Spondylolysis
. Degenerative disc disease
. Ankylosing spondylitis

Correct Answer & Explanation

. Spondylolysis

Explanation

In a young, active individual, especially military recruits or athletes involved in activities causing repetitive lumbar hyperextension, spondylolysis (a stress fracture of the pars interarticularis) is a common cause of low back pain. The pain is typically activity-related and relieved by rest. Lumbar disc herniation might present with radicular pain. Spinal epidural abscess would have systemic symptoms and neurological deficits. Degenerative disc disease is less common in this age group. Ankylosing spondylitis would typically have inflammatory pain characteristics (worse with rest, better with activity).

Question 7104

Topic: 6. Spine

Which of the following describes the mechanism of pain in neurogenic claudication?

. Ischemia of the spinal nerve roots due to compression during activity
. Ischemia of the leg muscles due to peripheral arterial disease
. Inflammation of the facet joints during lumbar extension
. Direct mechanical irritation of the sciatic nerve in the buttock
. Compression of the spinal cord leading to upper motor neuron signs

Correct Answer & Explanation

. Ischemia of the spinal nerve roots due to compression during activity

Explanation

Neurogenic claudication, primarily caused by lumbar spinal stenosis, results from ischemia of the spinal nerve roots within the narrowed spinal canal during activity. When standing or walking, the lumbar spine extends, further narrowing the canal and increasing pressure on the nerve roots, leading to reduced blood flow and pain/paresthesia. Resting or flexing the spine widens the canal, restoring blood flow and relieving symptoms. Vascular claudication involves muscle ischemia. Facet joint inflammation causes mechanical back pain. Sciatic nerve irritation in the buttock is piriformis syndrome. Spinal cord compression leads to myelopathy, which is distinct from claudication.

Question 7105

Topic: 6. Spine

A patient presents with acute onset of severe low back pain after a lifting injury. On examination, he holds his back rigidly and has marked paraspinal muscle spasm. He can ambulate but with difficulty. Neurological examination is normal. What is the most likely immediate diagnosis?

. Lumbar disc herniation with radiculopathy
. Spinal epidural abscess
. Vertebral compression fracture
. Acute lumbar muscle strain/ligamentous injury
. Cauda equina syndrome

Correct Answer & Explanation

. Acute lumbar muscle strain/ligamentous injury

Explanation

Acute onset low back pain after a lifting injury, associated with marked paraspinal muscle spasm and rigid posture, without neurological deficits, is most consistent with an acute lumbar muscle strain or ligamentous injury. This is a common diagnosis and usually responds well to conservative management. Lumbar disc herniation would typically involve radicular symptoms. Spinal epidural abscess and cauda equina syndrome are serious conditions with associated systemic symptoms or severe neurological deficits. Vertebral compression fracture would typically present with more focal tenderness and potentially a history of osteoporosis or significant trauma.

Question 7106

Topic: 6. Spine

A 70-year-old male with chronic low back pain and bilateral leg pain reports that his symptoms are worse when standing or walking, but improve significantly when he sits or leans forward. He often has to stop and rest during walks due to leg discomfort and weakness. His MRI shows degenerative changes but no significant disc herniation. What is the most appropriate next diagnostic step to confirm the cause of his leg symptoms?

. Electromyography (EMG) and nerve conduction studies (NCS)
. Vascular ultrasound of the lower extremities
. Lumbar epidural steroid injection
. Dynamic plain radiographs (flexion/extension) of the lumbar spine
. A trial of physical therapy focusing on extension exercises

Correct Answer & Explanation

. Vascular ultrasound of the lower extremities

Explanation

The patient's symptoms are classic for neurogenic claudication secondary to lumbar spinal stenosis. However, due to his age and the description of leg discomfort, vascular claudication (from peripheral arterial disease) remains a critical differential diagnosis. A vascular ultrasound of the lower extremities, along with ankle-brachial index (ABI) measurements, would be the most appropriate next diagnostic step to rule out or confirm a vascular component to his leg pain. EMG/NCS would confirm nerve damage but wouldn't differentiate vascular from neurogenic claudication. Epidural steroid injections are therapeutic, not primarily diagnostic for the cause of claudication (though a positive response can help confirm a spinal source). Dynamic plain radiographs assess for instability, not the specific cause of claudication. Extension exercises would likely worsen his symptoms if he has spinal stenosis.

Question 7107

Topic: 6. Spine

What is the typical presentation of inflammatory back pain, as seen in ankylosing spondylitis, compared to mechanical back pain?

. Inflammatory pain is worse in the evening, mechanical pain is worse in the morning.
. Inflammatory pain is relieved by rest, mechanical pain is exacerbated by rest.
. Inflammatory pain has an insidious onset, mechanical pain is usually acute.
. Inflammatory pain improves with exercise, mechanical pain worsens with exercise.
. Inflammatory pain is usually localized to the lumbar spine, mechanical pain radiates.

Correct Answer & Explanation

. Inflammatory pain improves with exercise, mechanical pain worsens with exercise.

Explanation

Inflammatory back pain, characteristic of spondyloarthropathies, typically presents with insidious onset, morning stiffness lasting >30 minutes, improvement with exercise, and worsening with rest/immobility. Mechanical back pain, on the other hand, usually has an acute or subacute onset, worsens with activity, improves with rest, and has morning stiffness lasting <30 minutes. Therefore, inflammatory pain improving with exercise and mechanical pain worsening with exercise is a key distinguishing feature. The other options describe contrasting or less typical features.

Question 7108

Topic: 6. Spine

A 48-year-old construction worker presents with low back pain and right leg pain that radiates into the posterior calf. He reports his symptoms are worse when bending forward and lifting, and sometimes when sitting. On examination, his right ankle jerk reflex is diminished. He has normal quadriceps strength and great toe extension strength. Which of the following is the most likely diagnosis?

. L4 radiculopathy
. L5 radiculopathy
. S1 radiculopathy
. Sacroiliac joint dysfunction
. Lumbar spinal stenosis

Correct Answer & Explanation

. S1 radiculopathy

Explanation

The patient's symptoms, including pain radiating to the posterior calf, and specifically a diminished right ankle jerk reflex, are classic for S1 radiculopathy. The S1 nerve root primarily controls plantarflexion and the ankle jerk reflex. L4 radiculopathy would involve the patellar reflex and quadriceps weakness. L5 radiculopathy affects great toe extension and ankle dorsiflexion, and typically has no reflex changes. Sacroiliac joint dysfunction would not typically affect reflexes. Lumbar spinal stenosis often presents with neurogenic claudication, which has a different pattern of exacerbating and relieving factors.

Question 7109

Topic: 6. Spine

In a patient presenting with back pain and a history of intravenous drug use, which 'red flag' diagnosis should be prioritized for investigation?

. Vertebral compression fracture
. Lumbar disc herniation
. Spinal epidural abscess or discitis
. Spondylolisthesis
. Facet joint arthritis

Correct Answer & Explanation

. Spinal epidural abscess or discitis

Explanation

A history of intravenous drug use significantly increases the risk of hematogenous spread of infection to the spine. Therefore, spinal epidural abscess or discitis (infection of the intervertebral disc and adjacent vertebrae) should be a primary concern and urgently investigated in an IV drug user presenting with back pain, especially if associated with fever, malaise, or neurological deficits. The other conditions are less directly linked to IV drug use and represent more common, often non-infectious, causes of back pain.

Question 7110

Topic: 6. Spine

A 55-year-old male with chronic low back pain undergoes an MRI that reveals multilevel degenerative disc disease and bilateral facet hypertrophy at L4-L5 and L5-S1. He also has mild central canal narrowing but no significant nerve root compression. Pain is worse with extension and rotation. What is the most appropriate initial management for his facet-mediated pain?

. Lumbar fusion surgery
. Epidural steroid injection
. Diagnostic facet joint injections followed by radiofrequency ablation if positive
. Aggressive core strengthening and flexibility exercises
. Long-term opioid analgesics

Correct Answer & Explanation

. Aggressive core strengthening and flexibility exercises

Explanation

The clinical picture of chronic low back pain, worsened by extension and rotation, with MRI findings of facet hypertrophy, strongly suggests facet-mediated pain. The initial management should focus on conservative measures, with aggressive core strengthening and flexibility exercises playing a crucial role in stabilizing the spine and reducing stress on the facet joints. While diagnostic facet joint injections followed by radiofrequency ablation are a valid treatment pathway for refractory facet pain, conservative physical therapy is almost always attempted first. Lumbar fusion surgery is a last resort for instability or refractory severe pain. Epidural steroid injections are primarily for radicular pain. Long-term opioid analgesics are generally avoided as first-line or long-term management due to significant risks.

Question 7111

Topic: 6. Spine

Which of the following is a common cause of back pain that typically resolves spontaneously within 4-6 weeks with conservative management?

. Spinal epidural abscess
. Malignant spinal tumor
. Cauda equina syndrome
. Acute lumbar muscle strain or sprain
. Severe spondylolisthesis

Correct Answer & Explanation

. Acute lumbar muscle strain or sprain

Explanation

Acute lumbar muscle strain or sprain is the most common cause of low back pain and typically resolves spontaneously within 4-6 weeks with conservative management (rest, NSAIDs, heat/ice, gentle activity). The other conditions listed are serious pathologies that require specific medical or surgical interventions and do not typically resolve spontaneously within this timeframe. Spinal epidural abscess, malignant spinal tumor, and cauda equina syndrome are 'red flag' conditions requiring urgent diagnosis and treatment. Severe spondylolisthesis can lead to chronic pain and potential neurological issues, often requiring more than conservative management to resolve.

Question 7112

Topic: 6. Spine

Which of the following conditions is characterized by pain that is often described as a 'deep ache' in the buttock, radiating down the posterior leg, and exacerbated by prolonged sitting or direct pressure on the buttock, sometimes with a positive straight leg raise test?

. Lumbar disc herniation
. Sacroiliac joint dysfunction
. Piriformis syndrome
. Proximal hamstring tendinopathy
. Lumbar spinal stenosis

Correct Answer & Explanation

. Piriformis syndrome

Explanation

Piriformis syndrome is characterized by buttock pain (deep ache) that may radiate down the posterior leg, mimicking sciatica, due to compression or irritation of the sciatic nerve by the piriformis muscle. It is typically exacerbated by prolonged sitting, direct pressure on the buttock, or activities that stretch the piriformis muscle. A positive straight leg raise may be present but often not as severe as with true disc herniation. Lumbar disc herniation typically has more specific dermatomal/myotomal patterns. Sacroiliac joint dysfunction is localized more specifically to the SI joint. Proximal hamstring tendinopathy causes pain more directly at the ischial tuberosity. Lumbar spinal stenosis causes neurogenic claudication.

Question 7113

Topic: Thoracolumbar Spine & Deformity

Which of the following is a common cause of back pain in older adults that involves anterior slippage of one vertebral body over another without a pars interarticularis defect?

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

Correct Answer & Explanation

. Degenerative spondylolisthesis

Explanation

Degenerative spondylolisthesis is the most common form of spondylolisthesis in older adults. It results from chronic disc degeneration and facet joint arthritis, leading to instability and gradual forward slippage of one vertebra over another (most commonly L4 over L5). Unlike isthmic spondylolisthesis, there is no pars interarticularis defect. Dysplastic is congenital, pathologic is due to systemic bone disease, and traumatic is from acute fracture. Isthmic is due to pars defect, typically in younger individuals.

Question 7114

Topic: 6. Spine

A 25-year-old female presents with acute onset, severe low back pain after a fall. She reports difficulty bearing weight and tenderness to percussion over the L3 vertebral body. She has no neurological deficits. What is the most appropriate initial imaging study?

. Plain radiographs of the lumbar spine (AP/lateral)
. MRI of the lumbar spine
. CT scan of the lumbar spine
. Bone scan
. Electromyography (EMG)

Correct Answer & Explanation

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

Explanation

In the setting of acute, severe, focal back pain after trauma with tenderness to percussion over a vertebral body, a vertebral fracture is a primary concern. Plain radiographs (AP and lateral views) are the initial imaging of choice to screen for fractures and assess alignment. If radiographs are normal but suspicion remains high, or if further characterization is needed, CT scan would be the next step for superior bony detail. MRI is excellent for soft tissue and cord assessment but less sensitive than CT for acute bony trauma. Bone scan detects stress reactions or metabolic activity, and EMG assesses nerve function.

Question 7115

Topic: 6. Spine

A 50-year-old male with a history of intravenous drug use and recent fever presents with new-onset, severe low back pain that has become progressively worse over 3 days. He now reports leg weakness and numbness. His ESR and CRP are significantly elevated. What is the most urgent diagnostic test?

. Plain radiographs of the lumbar spine
. CT scan of the lumbar spine
. MRI of the lumbar spine with contrast
. Electromyography (EMG)
. Blood cultures

Correct Answer & Explanation

. MRI of the lumbar spine with contrast

Explanation

This patient presents with multiple 'red flags' for spinal infection (IV drug use, fever, progressively worsening pain, elevated inflammatory markers, and new neurological deficits). These symptoms are highly suggestive of a spinal epidural abscess or discitis with potential cord compression. MRI of the lumbar spine with contrast is the most urgent diagnostic test. It is the gold standard for visualizing spinal infections, epidural collections, and assessing the degree of spinal cord compression. Plain radiographs and CT scans are less sensitive for early infection and soft tissue involvement. Blood cultures are important for identifying the causative organism but do not provide immediate anatomical information about cord compression. EMG assesses nerve function but is not the most urgent diagnostic for infection/compression.

Question 7116

Topic: 6. Spine

A patient with long-standing back pain reports that his pain is worse when driving for long periods, relieved somewhat by frequent stops and stretching. He denies radicular symptoms. On examination, there is tenderness over the left greater trochanter and pain with resisted hip abduction. Lumbar spine examination is otherwise unremarkable. What is the most likely source of his pain?

. Lumbar disc herniation
. Lumbar spinal stenosis
. Trochanteric bursitis
. Sacroiliac joint dysfunction
. Facet joint arthropathy

Correct Answer & Explanation

. Trochanteric bursitis

Explanation

The localized tenderness over the greater trochanter, pain with resisted hip abduction, and exacerbation with prolonged sitting (which compresses the bursa) are classic signs of trochanteric bursitis. While back pain can be present as a separate issue or referred, the specific findings point strongly to this hip region pathology. Lumbar disc herniation would present with radicular pain. Lumbar spinal stenosis would cause neurogenic claudication. Sacroiliac joint dysfunction would cause pain more medially in the buttock/SI region. Facet joint arthropathy would be worse with extension/rotation. This highlights the importance of considering non-spinal causes of back and hip region pain.

Question 7117

Topic: 6. Spine

Which of the following features is most characteristic of discogenic pain without radiculopathy?

. Pain primarily in the lower extremities, extending below the knee.
. Pain that is worse with flexion, sitting, and Valsalva maneuvers, but no nerve root signs.
. Pain relieved by standing and walking, worsened by sitting.
. Morning stiffness lasting several hours, improving with activity.
. Pain localized to the sacroiliac joint, provoked by unilateral weight bearing.

Correct Answer & Explanation

. Pain that is worse with flexion, sitting, and Valsalva maneuvers, but no nerve root signs.

Explanation

Discogenic pain, particularly from internal disc disruption or a contained disc bulge, can cause significant low back pain without specific radicular symptoms. This type of pain is typically exacerbated by activities that increase intradiscal pressure, such as flexion, sitting, and Valsalva maneuvers. It is usually localized to the central lower back and may radiate into the buttocks or thighs, but generally not below the knee in a dermatomal pattern (which would indicate radiculopathy). Pain primarily in the lower extremities or relieved by standing/walking suggests other conditions. Morning stiffness improving with activity suggests inflammatory back pain. Pain localized to the SI joint suggests SIJ dysfunction.

Question 7118

Topic: 6. Spine

Which of the following statements regarding the role of X-rays in the initial evaluation of acute, non-specific low back pain is most accurate?

. X-rays are routinely recommended for all patients with acute low back pain.
. X-rays are primarily useful for evaluating soft tissue structures like discs and nerves.
. X-rays are most indicated when 'red flag' symptoms are present.
. X-rays have higher diagnostic yield than MRI for cauda equina syndrome.
. X-rays can definitively rule out spinal infection or malignancy.

Correct Answer & Explanation

. X-rays are most indicated when 'red flag' symptoms are present.

Explanation

Plain radiographs (X-rays) are generally not recommended for the routine initial evaluation of acute, non-specific low back pain without 'red flag' symptoms, as they have low yield and expose the patient to unnecessary radiation. Their primary utility is when 'red flag' symptoms are present (e.g., trauma, suspicion of fracture, history of cancer, fever, neurological deficits) to screen for bony pathology, instability, or significant deformity. X-rays are poor for soft tissue visualization (discs, nerves) and cannot definitively rule out spinal infection or malignancy, which require advanced imaging like MRI. MRI is the gold standard for cauda equina syndrome.

Question 7119

Topic: 6. Spine

A 35-year-old patient reports chronic pain radiating from the low back into the right buttock and posterior thigh, occasionally reaching the knee. Pain is worse with prolonged sitting and during bowel movements. Physical examination reveals tenderness in the sciatic notch and pain reproduction with passive internal rotation and adduction of the right hip while the hip is flexed. What is the most likely diagnosis?

. L5-S1 disc herniation
. Sacroiliac joint dysfunction
. Piriformis syndrome
. Proximal hamstring tear
. Lumbar facet arthropathy

Correct Answer & Explanation

. Piriformis syndrome

Explanation

The clinical presentation of chronic buttock and posterior thigh pain, exacerbated by prolonged sitting and bowel movements, tenderness in the sciatic notch, and pain with maneuvers that stretch or contract the piriformis muscle (passive internal rotation, adduction, flexion of the hip, e.g., FAIR test or Freiberg sign), is highly suggestive of piriformis syndrome. This condition involves irritation or compression of the sciatic nerve by the piriformis muscle. While L5-S1 disc herniation can cause similar pain, the specific physical exam findings point more strongly to piriformis syndrome, which is often a diagnosis of exclusion after ruling out true radiculopathy. Sacroiliac joint dysfunction pain is usually more medial. Proximal hamstring tear would cause pain directly at the ischial tuberosity. Facet arthropathy would be more localized to the lumbar spine and worsen with extension/rotation.

Question 7120

Topic: 6. Spine

Which of the following diagnostic procedures involves injecting anesthetic and potentially a corticosteroid into the epidural space, and is used for both diagnosis and treatment of radicular pain?

. Medial branch block
. Facet joint injection
. Radiofrequency ablation
. Epidural steroid injection
. Discography

Correct Answer & Explanation

. Epidural steroid injection

Explanation

An epidural steroid injection (ESI) involves injecting anesthetic and corticosteroids into the epidural space surrounding the nerve roots. It is widely used to diagnose the source of radicular pain (if a specific nerve root is targeted and provides relief) and to treat the inflammation and pain associated with nerve root compression (e.g., from a disc herniation or spinal stenosis). Medial branch blocks and facet joint injections target the nerves supplying the facet joints, used for facet-mediated pain. Radiofrequency ablation is a neurolytic procedure for long-term pain relief from facet or sacroiliac joint pain. Discography is a provocative test to determine if a specific disc is a pain generator, and it's controversial.

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