Full Question & Answer Text (for Search Engines)
Question 1:
Unilateral facet dislocation may be distinguished radiographically from bilateral facet dislocation by which of the following features:
Options:
- Misalignment of the spinous processes
- Subluxation >50%
- Subluxation <25%
- Marked angular deformity
- Spinal canal compromise
Correct Answer: Subluxation >50%
Explanation:
Unilateral jumped facets typically involve anterolisthesis of the upper vertebral body, which is less than 25%. Misalignment of the spinous processes and spinal canal compromise may be seen with either unilateral or bilateral facet dislocation. Subluxation greater than 50% and marked angular deformity are characteristics of bilateral facet dislocations.
Question 2:
The annual incidence of cervical radiculopathy in men is 107.3 per 100,000 and 63.5 per 100,000 in women. The incidence for both groups occurs within which of the following peak age ranges:
Options:
- 45-49 years
- 50-54 years
- 55-59 years
- 60-64 years
- 65-69 years
Correct Answer: 50-54 years
Explanation:
Although the incidence rate of cervical radiculopathy in men is nearly double the rate found in women, the peak age range is the same (50-54 years).
Question 3:
Which of the following structures are found within an intervertebral foramen:
Options:
- Dorsal root ganglion
- C onnective tissue
- Radicular artery and vein
- Recurrent meningeal nerves
- All of the above
Correct Answer: All of the above
Explanation:
In addition to the dorsal root ganglion, connective tissue, radicular artery and vein, and recurrent meningeal nerves, spinal nerve roots and adipose also comprise an intervertebral foramen.
Question 4:
Most cervical radiculopathy occurs as a result of inflammatory mediators released after mechanical injury, without direct compression of the nerve root(s).
Options:
- True
- False Approximately 75% of cervical radiculopathies occur as a result of direct compression of nerve roots, with at least one study noting a pressure of only 10 mm Hg produced significant conduction block, the potential [of nerve impulses] falling under 60 percent of its initial value in 15 minutes. With higher levels of pressure, we have observed incomplete recovery after many hours of recording.Disk protrusion, with the associative release of inflammatory mediators, is responsible for up to 25% of cervical radiculopathies. One study even suggests â chemical release from the nucleus pulposus into the nerve root epidural space, without herniation of the nucleus pulposus and without direct nerve root compression, caused radiculopathic pain in an animal model.
Correct Answer: False Approximately 75% of cervical radiculopathies occur as a result of direct compression of nerve roots, with at least one study noting a pressure of only 10 mm Hg produced significant conduction block, the potential [of nerve impulses] falling under 60 percent of its initial value in 15 minutes. With higher levels of pressure, we have observed incomplete recovery after many hours of recording.Disk protrusion, with the associative release of inflammatory mediators, is responsible for up to 25% of cervical radiculopathies. One study even suggests â chemical release from the nucleus pulposus into the nerve root epidural space, without herniation of the nucleus pulposus and without direct nerve root compression, caused radiculopathic pain in an animal model.
Question 5:
C1 reflexes include which of the following:
Options:
- Sternocleidomastoid reflex
- Clavicle reflex
- Deltoid reflex
- Jaw jerk
- Biceps reflex
Correct Answer: Jaw jerk
Explanation:
The C 1 reflex, while rarely tested, involves the jaw jerk.
Question 6:
Typical C 3 reflexes include which of the following:
Options:
- Sternocleidomastoid reflex
- Head retraction reflex
- Pectoralis reflex
- Biceps reflex
- None of the above
Correct Answer: None of the above
Explanation:
No reflexes are associated with the C3 spinal nerve.
Question 7:
Which of the following is a distinguishing feature of a C 7 radiculopathy rarely found in C 6 radiculopathies:
Options:
- Paresthesia of the middle finger
- Anterior chest pain
- Little to no pain in associated muscles
- Epaulet pain in the associated shoulder and lateral arm
- None of the above
Correct Answer: Paresthesia of the middle finger
Explanation:
C 7 radiculopathies classically entail pain and/or sensory changes involving the middle finger. C 6 radicular symptoms generally involve the thumb and first finger. C 8 radiculopathies involve the pinkie and ring fingers.
Question 8:
Studies suggest that cervical radiculopathy (or related pathology) of which nerve root may partially explain the phenomenon of cervicogenic headaches:
Options:
Correct Answer: C 3
Explanation:
Headaches observed with upper cervical pathology may be due, in part, to the convergence of C 1-, C 2-, and C 3-level pain fibers with second-order neurons of the descending sensory tract of cranial nerve V.
Question 9:
Which of the following diagnostic tests is preferred for suspected cervical radiculopathy:
Options:
- C hest radiograph
- Magnetic resonance imaging
- C -reactive protein assay
- Myelogram
- All of the above
Correct Answer: Magnetic resonance imaging
Explanation:
Although myelogram and nerve conduction studies are useful tests, they are invasive. Magnetic resonance imaging studies are the most appropriate choice for diagnosis. Most important in the diagnosis of cervical radiculopathy is a thorough history and physical examination.
Question 10:
What is the preferred treatment method for patients with cervical radiculopathy:
Options:
- Physical therapy
- Surgical repair
- Medical management (eg, nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids)
- Bed rest
- None of the above
Correct Answer: Medical management (eg, nonsteroidal anti-inflammatory drugs, opioids, and corticosteroids)
Explanation:
Most patients with cervical radiculopathy are best treated medically after the age of 50. In other age groups, based on the history, physical examination, and number of involved nerve roots, a combination of the above methods may be appropriate. Surgical therapy may be necessary in patients refractory to medical management.
Question 11:
A 17-year-old high school football player presents to the emergency department after being removed from play following a harsh tackle. The patient reports a sharp burning and stinging pain through his left arm that has not resolved since the tackle. A careful history revealed that this is the fourth episode of burning and stinging pain. In each episode of pain, the symptoms have lasted longer than the previous episode. The patient also reports that he has suffered from two prior episodes of transient weakness and numbness in all extremities following harsh tackles. Which of the following statements concerning this patient is correct:
Options:
- There is no contraindication to return to play in this patient.
- There is a relative contraindication to return to play in this patient.
- There is an absolute contraindication to return to play in this patient.
- Because this patient has suffered repeated episodes of transient pain after tackles, he is obviously experienced enough to not need education and counseling to help prevent recurrence.
- The patient should not participate in football games, but should feel free to continue lifting weights and practicing.
Correct Answer: There is an absolute contraindication to return to play in this patient.
Explanation:
It is important to understand the current return to play criteria for cervical spine injuries in athletes. There is an absolute contraindication to return to play in patients who have: a) more than two previous episodes of transient quadriparesis/quadriplegia, b) clinical history, physical examination findings, or imaging confirmation of cervical myelopathy/myelomalacia, and c) continued cervical neck discomfort, decreased range of motion, or any evidence of a neurologic deficit from baseline after any cervical spine injury. Patient education and follow-up are always indicated in patients with burners and stingers. This patient should not participate in football games, exercise, or practice until full mobility and strength has returned, and all neurologic symptoms have resolved.
Question 12:
Which of the following statements regarding radiographic evaluation of patients with burners and stingers is correct:
Options:
- A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present.
- A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present.
- An extension lateral cervical conventional radiograph is used to determine the Torg ratio.
- A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.
- A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.
Correct Answer: A Torg ratio > 0.8 indicates that cervical spinal stenosis may be present.
Explanation:
The Torg ratio is calculated using an extension lateral cervical radiograph. To calculate the Torg ratio, divide the distance between the midpoint of the posterior aspect of the vertebral body to the nearest point on the corresponding spinolaminar line by the anteroposterior width of the vertebral body. A Torg ratio , 0.8 is associated with cervical spinal stenosis and sustained burners and stingers in athletes with cervical spine-extension- compression type injuries.C orrect Answer: A Torg ratio , 0.8 indicates that cervical spinal stenosis may be present, and an extension lateral cervical conventional radiograph is used to determine the Torg ratio.
Question 13:
Which of the following statements concerning burners and stingers is incorrect:
Options:
- Burners and stingers typically result from depression of the ipsilateral shoulder and deviation of the neck to the contralateral side.
- Burners and stingers are commonly seen in elderly patients.
- In treating burners and stingers, it is important to restore pain-free mobility in the upper extremities by strengthening and stretching.
- Follow-up and patient education are important in all cases of burners and stingers, regardless of the duration of symptoms.
- None of the above
Correct Answer: Burners and stingers typically result from depression of the ipsilateral shoulder and deviation of the neck to the contralateral side.
Explanation:
Burners and stingers are usually seen in children, adolescents, and athletes. Choice A is correct, and explains why burners and stingers are typically seen in tackle injuries sustained by football players and in motorcycle accidents. Choices C and D are correct because management of patients with burners and stingers should always include strengthening, stretching, patient education, and follow-up.
Question 14:
A 26-year-old man with HIV presents to your office with symptoms of lower back pain, difficulty with ambulation, loss of appetite, mild fever, and malaise for 2 weeks. The patient states that he has had difficulty with compliance to his medical management. You suspect that he has a low C D4 count, which is confirmed by laboratory tests. Physical examination reveals tenderness at the L4-L5 level. The patient has abnormal gait. Ankle dorsiflexion and plantarflexion are 1 out of 5 bilaterally. The Achilles tendon reflex is absent bilaterally; all other reflexes are normal. A T2-weighted magnetic resonance imaging (MRI) study shows slightly increased intensity of the disk at the L4-L5 level and an obvious epidural abscess. C onventional radiographs of the lumbar region are normal. Management of this patient should consist of:
Options:
- Admission to the intensive care unit (IC U) and intravenous administration of broad-spectrum antibiotics
- C onsideration of urgent surgical intervention and evacuation of the epidural abscess
- C ounseling the patient on the importance of compliance with medical management
- Surveillance for signs of further neurologic deterioration
- All of the above
Correct Answer: All of the above
Explanation:
All of the above answer choices are correct. The patient described above has HIV and is severely immunocompromised. Because of the severity of the patientâ s condition, immediate admission to the ICU and intravenous administration of a broad-spectrum antibiotic regimen is indicated. Biopsy and drainage of the infected regions should be performed. It is important in this case to monitor the patient for any signs of neurologic deterioration. Finally, to prevent recurrent cases of diskitis, or other infections, it is important to counsel the patient on compliance with medical management.
Question 15:
Which of the following statements regarding diskitis is correct:
Options:
- Signs and symptoms of diskitis generally progress rapidly.
- Intravenous drug use and immunocompromise are not generally considered risk factors for diskitis.
- Diskitis commonly occurs in the thoracic region of the spine.
- Blood cultures are generally positive in up to 70% of patients with diskitis.
- All of the above
Correct Answer: Blood cultures are generally positive in up to 70% of patients with diskitis.
Explanation:
Diskitis is usually indolent, and patients live with symptoms for several months before seeking treatment. Intravenous drug use and immunocompromise are two important risk factors for diskitis, along with surgical procedures involving the spine. Diskitis rarely occurs in the thoracic spine; instead, diskitis usually occurs in the lumbar spine. Blood cultures should be taken in any patient with suspected diskitis.
Question 16:
Which of the following statements regarding lesions of the spinal cord caused by bullet wounds is true:
Options:
- Twenty-five percent of patients with complete lesions recover one motor level after 1 year.
- Thirty-three percent of patients with incomplete lesions usually have a partial or complete recovery after 1 year.
- Complete lesions occur in more than 50% of all gunshot wounds to the spine.
- Seventy-five percent of patients in whom the bullet has passed through the spinal canal will experience a complete lesion.
- All of the above
Correct Answer: All of the above
Explanation:
All of the statements are true. Knowledge of these facts is important in decision-making and management of patients who are victims of gunshot wounds to the spine.
Question 17:
An 18-year-old man presents to the emergency department after sustaining a high-velocity gunshot wound to the umbilical region of the abdomen. An exit wound is found at the L3-L5 region of the lower back. Neurological examination shows grade 0/5 strength in his tibialis anterior muscles, gastrocnemius/soleus muscles, and extensor hallucis longus muscles bilaterally. His quadriceps and hamstrings strength is grade 2/5 bilaterally. A bullet fragment was seen at L4 within the spinal canal on computed tomography (C T) imaging. The patient sustained significant gastrointestinal trauma as a result of the bullet traversing his body. Management should consist of:
Options:
- Administration of a broad-spectrum antibiotic for 14 days
- Removal of the bullet fragment at L4
- Continued serial neurologic examinations
- Intravenous administration of dexamethasone for 24 hours
- A, B, and C
Correct Answer: A, B, and C
Explanation:
Because the bullet entered the patientâ s umbilical region of the abdomen, significant gastrointestinal damage is suspected. When this occurs, administration of a broad-spectrum antibiotic for 7 to 14 days is indicated to prevent infection and sepsis from gastrointestinal flora. The bullet fragment at L4 should be removed because studies have shown that removal of a bullet from a patient with complete or incomplete neural deficits at T12 to L4 is associated with statistically significant increases in motor recovery as compared to nonoperative management. Intravenous administration of dexamethasone is not indicated for gunshot wounds to the spine because the benefits of steroids do not outweigh the risks.
Question 18:
Magnetic resonance imaging (MRI) is appropriate in which of the following circumstances:
Options:
- Malignancy is suspected as a cause of kyphosis
- Neurologic deficit is suspected as a result of kyphosis
- Patient with congenital kyphosis
- Patient with back pain and a history of osteoporosis
- All of the above
Correct Answer: All of the above
Explanation:
It is appropriate to obtain an MRI in all of the above circumstances. Magnetic resonance imaging allows a physician to evaluate the cerebrospinal fluid and spinal cord to localize the cause of a neurologic deficit. The presence of back pain in a patient with kyphosis and osteoporosis suggests the possibility of a vertebral compression fracture; these fractures may not always be seen with conventional radiographs. The use of MRI is recommended for the evaluation of a patient with congenital kyphosis to evaluate the morphology of the malformed segment and to rule out associated pathology.
Question 19:
What percentage of women with osteoporotic fractures develop kyphosis:
Options:
Correct Answer: 15%
Explanation:
Approximately 15% of women with osteoporotic fractures develop kyphosis. This is often due to the presence of multiple vertebral compression fractures with segmental kyphosis at each level.
Question 20:
A 7-year-old boy presents to the emergency department (ED) with fever, headache, neck pain, nausea, vomiting, and mental status changes. The patient was involved in a motor vehicle accident in his parentâ s car and experienced whiplash 4 weeks prior to his presentation at the ED. Laboratory studies show an elevated white blood cell (WBC ) count and erythrocyte sedimentation rate (ESR). Which of the following statements concerning this patient is correct:
Options:
- A lumbar puncture may reveal cerebral spinal fluid (C SF) with an increased number of neutrophils, decreased glucose content, and increased protein levels.
- A CSF culture may reveal Haemophilus influenzae.
- Radiographic findings for whiplash-related trauma may be negative in this patient.
- The patient should be admitted to the pediatric intensive care unit (PIC U) and started on an intravenous antibiotic regimen.
- All of the above
Correct Answer: All of the above
Explanation:
The patient presented with the classic signs and symptoms of pediatric bacterial meningitis. Meningitis should be suspected in patients with neck pain, fever, and altered mental status. A lumbar puncture may show C SF with a high neutrophil count, high protein level, and decreased glucose; a C SF culture may reveal bacteria such as H influenzae. In children with a history of trauma, it is important to note that no radiographic findings may be present in 19% to 34% of patients. Because of the severity of the patients symptoms and diagnosis of bacterial meningitis, it is important to admit him to the PIC U and begin intravenous antibiotics.
