Full Question & Answer Text (for Search Engines)
Question 1:
A 72-year-old man with acute onset low back pain with increased severity during the night should be evaluated by:
Options:
- History and physical examination only
- Magnetic resonance imaging of the lumbar spine
- History, examination, and urine protein electrophoresis
- C omputed tomography of the lumbar spine
- Plain radiographs of the lumbar spine
Correct Answer: Magnetic resonance imaging of the lumbar spine
Explanation:
An elderly patient with unsolicited low back pain is suggestive of a primary malignancy or metastatic disease of the lumbar spine. A thorough history and physical examination are indicated, as well as imaging to evaluate the lumbar spinal axis and the neural elements.
Question 2:
An otherwise healthy 56-year-old patient with suspected spinal stenosis after history and physical examination undergoes plain radiography that is unremarkable for spondylolisthesis. The next feasible imaging modality that is indicated in aiding the diagnosis is:
Options:
- No more imaging studies are needed
- A computed tomography myelogram
- Magnetic resonance imaging
- Ultrasound
- Spinal angiogram
Correct Answer: Magnetic resonance imaging
Explanation:
Although a computed tomography myelogram is slightly more specific and sensitive than magnetic resonance imaging (MRI) in evaluating lumbar stenosis, MRI is almost as sensitive and it is noninvasive. Therefore, in an otherwise healthy patient without contraindications, an MRI should be considered as the next imaging modality.
Question 3:
Untreated low back pain most commonly:
Options:
- Improves spontaneously
- Undergoes progressive worsening prompting further medical care
- Leads to neurological decompensation
- No studies have been done to evaluate the natural history of untreated low back pain.
- Progresses to chronic failed back syndrome
Correct Answer: Improves spontaneously
Explanation:
Generally, patients diagnosed with low back pain should undergo 4 weeks of conservative treatment with an accepted prognosis of predominantly spontaneous improvement over a 4-week period, regardless of treatment.
Question 4:
Which of the following is NOT a routinely used imaging modality for evaluation of spinal pathology:
Options:
- Plain radiography
- C omputed tomography
- Magnetic resonance imaging
- Diskography
- Myelogram
Correct Answer: Diskography
Explanation:
Diskography is a diagnostic technique that has been used since the 1950â s. The study involves injection of dye into an intervertebral disk space. A positive study is one in which the injected dye is not contained within the disk space or in which the injection reproduces the characteristic distribution of the patientâ s pain. The current role of diskography remains undefined and, at this time, diskography is not a first-line diagnostic study in the evaluation of patients with low back pain.
Question 5:
Which of the following is the most common type of spondylolisthesis seen in the adult population:
Options:
- Degenerative
- Isthmic
- C ongenital
- Traumatic
- Pathologic
Correct Answer: Degenerative
Explanation:
The prevalence of degenerative spondylolisthesis is 2% to 5%; the prevalence increases with age. Symptomatic patients usually present in the fourth decade of life or later. The disease is five times more common in the female sex. The African American population, diabetics, and patients with sacralization of the L5 vertebrae are also at increased risk for developing symptomatic spondylolisthesis.
Question 6:
Which of the following is the most common location of adult degenerative spondylolisthesis:
Options:
- L1-L2 interspace
- L2-L3 interspace
- L3-L4 interspace
- L4-L5 interspace
- L5-S1 interspace
Correct Answer: L4-L5 interspace
Explanation:
The L4-L5 interspace is the most common location of adult degenerative spondylolisthesis.
Question 7:
Which of the following statements is true regarding the initial diagnostic radiographic evaluation of patients with spondylolisthesis:
Options:
- Initial diagnostic radiographic evaluation includes plain radiographic imaging of lumbar spine with flexion and extension.
- C omputed tomography of the lumbar spine region is the first order diagnostic imaging study.
- Spondylolisthesis is a clinical diagnosis; no imaging studies are indicated.
- Initial diagnostic radiographic evaluation includes magnetic resonance imaging of the lumbar spine to evaluate spinal stenosis and nerve root compression.
- If spondylolisthesis is suspected, myelogram is necessary for diagnosis.
Correct Answer: Initial diagnostic radiographic evaluation includes plain radiographic imaging of lumbar spine with flexion and extension.
Explanation:
Plain radiographs should be performed in a standing position as some cases of spondylolisthesis can be missed if x-rays are taken in a supine position. Forward displacement of L4 on L5 and more rarely L5 on S1 or L3 on L4, without a pars interarticularis defect is often demonstrated. Other radiologic findings of osteophyte formation, such as disk-space narrowing, endplate sclerosis, vacuum disk sign, facet sclerosis and hypertrophy, are consistent with long-standing degenerative disease. Hemisacralization of L5 may be revealed. Flexion, extension, and lateral bending films often reveal hypermobility.
Question 8:
Initial nonoperative management of adult degenerative spondylolisthesis includes all of the following except:
Options:
- Physical therapy
- Anti-inflammatory medication
- Modified activity
- Strict bed rest
- Support brace
Correct Answer: Strict bed rest
Explanation:
Conservative treatment for degenerative spondylolisthesis is consistent with the conservative care of most degenerative spinal disorders. It includes modified activity, physical therapy (conditioning exercises emphasizing lumbar flexion and progression to aerobic conditioning), anti-inflammatory medication, and sometimes spinal support with a corset or light-weight brace.
Question 9:
Which of the following statements is true regarding lumbar degenerative scoliosis:
Options:
- Lumbar degenerative scoliosis is most commonly distributed to the left.
- Lumbar degenerative scoliosis is most commonly distributed to the right.
- Lumbar degenerative scoliosis is most commonly evenly distributed between left and right.
- The distribution of lumbar degenerative scoliosis depends on age of patient at the time of onset.
- No data are available.
Correct Answer: Lumbar degenerative scoliosis is most commonly distributed to the left.
Explanation:
Degenerative lumbar scoliosis occurs in approximately the same number of women as men. Lumbar curves are generally smaller than those in idiopathic scoliosis and are more evenly distributed between left and right, also in contrast to idiopathic curves that occur predominantly to the left.
Question 10:
Which of the following is the most common complaint in patients with degenerative lumbar scoliosis:
Options:
- Radicular pain radiating to one or the other leg
- Mechanical pain during motion
- Low back pain and reduced tolerance for walking
- Urinary incontinence
- Sensory changes at the dorsal feet bilaterally
Correct Answer: Low back pain and reduced tolerance for walking
Explanation:
Patients with degenerative lumbar scoliosis typically complain of symptoms related to the associated spinal stenosis. These symptoms commonly include (with approximate incidence rates): low back pain (100%), reduced tolerance for standing and walking (85% to 100%), neurogenic claudication (50%), and radicular or pseudoradicular pain radiating into the buttocks or thighs (40% to 60%).
Question 11:
Bony contribution to the lumbar lordotic curvature is provided by:
Options:
- Spinous processes
- Articulating facets
- Lamina
- Pars interarticularis
- Vertebral body
Correct Answer: Vertebral body
Explanation:
The anterior portion of each body has a slightly increased height that contributes to the sagittal lumbar lordosis. The posterior vertebral arch consists of the paired pedicles, laminae, and a midline dorsal spinal process.
Question 12:
Superior articulating facets in the lumbosacral spine differ from those in the thoracic spine because facets in the lumbosacral spine:
Options:
- Face posteriorly
- Face dorsomedially
- Have a thicker facet joint capsule
- Face superolaterally
- Are fused and are not true joints
Correct Answer: Face dorsomedially
Explanation:
The paired superior articular facets are directed dorsomedially with their corresponding inferior articular processes directed ventrolaterally. These diarthrodial articulations possess thin, lax joint capsules capable of a limited gliding articulation between adjoining vertebrae. They permit flexion, lateral bending and extension, but resist rotation due to both size and facet orientation. The facets alone can bear up to 18% of the compressive load.
Question 13:
Limitation of hyperextension in the lumbosacral spine is controlled by the:
Options:
- Posterior longitudinal ligament
- Anterior longitudinal ligament
- Ligamentum flavum
- Interspinous ligament
- Intertransverse ligament
Correct Answer: Anterior longitudinal ligament
Explanation:
More flexion-extension motion occurs in the caudal segments of the lumbar spine than in the upper and middle levels. The welldeveloped anterior longitudinal ligament and the anterior portion of the annulus fibrosus are important inhibitors of hyperextension.
Question 14:
Which of the following is the primitive remnant of the nucleus pulposus:
Options:
- The smoites
- Ectoderm
- Midgut
- Rhombencephalon
- Notocord
Correct Answer: Notocord
Explanation:
The nucleus pulposus is derived from the primitive notochord. It consists predominantly of hydrated proteoglycans with a minor component of a random network of type I and type II collagen.
Question 15:
Which of the following is the most common region of the spine affected by metastatic disease:
Options:
- Craniocervical junction
- Cervical region
- Thoracic region
- Lumbar region
- Sacral region
Correct Answer: Thoracic region
Explanation:
The thoracic spine is the most common site of metastatic disease. This has been attributed to the watershed zone being located in the low thoracic region.
Question 16:
Which of the following is the most common complaint at time of presentation in patients with metastatic spine disease:
Options:
- Difficulty with balance
- Difficulty with urination
- Night sweats
- Pain during the night
- Numbness in the lower extremities
Correct Answer: Pain during the night
Explanation:
The most common manifestation of metastatic disease is persistent pain. Pain is most marked at night and aggravated by movement. History of trauma is usually absent. Pain is followed by weakness of the lower extremities, sensory loss, and bladder and bowel changes.
Question 17:
Which of the following methods is the standard in diagnosing vertebral metastatic disease:
Options:
- Plain radiography demonstrating lytic lesion
- C omputed tomography with bony destruction respecting adjacent vertebral levels
- Magnetic resonance imaging with typical destructive lesion characteristics
- Tissue biopsy
- There is no standard of care in diagnosing vertebral metastasis.
Correct Answer: Tissue biopsy
Explanation:
The only definitive method of determining the presence and nature of metastatic tumor is vertebral biopsy. Computed tomography-guided biopsy of the spine provides an accurate access to the lesion. Open biopsy is indicated when image guided biopsy is not feasible or non-diagnostic. Differential diagnosis mainly involves spinal infections, osteoporosis, disk disease, and multiple myeloma.
Question 18:
Which of the following is NOT an indication for surgical intervention in metastatic vertebral disease:
Options:
- Progressive neurologic deficit
- Poor prognosis
- Instability of the spine
- Uncontrollable pain
- Failure of radiation therapy
Correct Answer: Poor prognosis
Explanation:
In patients with metastatic vertebral disease, indications for surgery include progressive neurologic deficit, instability of the spine, uncontrollable pain, and failure of radiation therapy. Surgical intervention can add significant morbidity while providing marginal improvement in longevity of a patient with an already poor prognosis.
Question 19:
Which of the following is the most common cause of lumbar stenosis:
Options:
- Congenital
- Posttraumatic
- Degenerative
- Iatrogenic
- Idiopathic
Correct Answer: Degenerative
Explanation:
Degenerative lumbar stenosis is the most common cause of lumbar stenosis. With normal aging of the disk, the water-binding capacity of the nucleus pulposus is dissipated, diminishing its ability to withstand normal compressive and rotational forces. With progressive degeneration of the disk, collapse occurs. This collapse results in overriding of the facet joints and relative lengthening of adjacent capsular and ligamentous structures. Continued instability, which may be multidirectional, results in hypertrophic changes about the periphery of the vertebral body at its annular attachments. Radiographically, these are seen as traction osteophytes. Similarly, osteophytes form about the facet joints, which lead to compromise of the neural canal. With disease progression, hypertrophic changes predominate, leading to ankylosis and auto stabilization. In patients with less than optimal canal configurations or dimensions or those with excessive hypertrophic degenerative changes, narrowing of the spinal canal, lateral recesses, and neural foramina may result in neurogenic signs and symptoms.
Question 20:
Which of the following is the most common presentation of a patient with lumbar stenosis:
Options:
- Foot drop
- Acute onset of pain in bilateral lower extremities
- C hronic low back pain with neurogenic claudication
- Saddle anesthesia
- Intermittent urinary incontinence
Correct Answer: C hronic low back pain with neurogenic claudication
Explanation:
The most common complaint in patients with spinal stenosis is chronic low back pain with worsening and lower extremity weakness after ambulation (claudication). Symptoms are often resolved by rest and/or leaning forward.
