Full Question & Answer Text (for Search Engines)
Question 1:
A 12-year-old girl presents to the clinic with scoliosis detected by school screening. Her past medical history includes ophthalmologic observation for Lisch nodules of the iris. She has just started her menstrual periods. On physical exam, she has axillary freckles and normal neurological function. Standing radiographs of the spine illustrate a 32° right thoracic curve from T4 to T10 and rib pencilling. In the sagittal plane, she has a thoracic kyphosis of 30°. The most likely diagnosis is:
Options:
- Adolescent idiopathic scoliosis
- C ongenital kyphoscoliosis
- Neurofibromatosis-1 (NF-1)
- Neurofibromatosis-2 (NF-2)
- Stickler disease
Correct Answer: Neurofibromatosis-1 (NF-1)
Explanation:
Neurofibromatosis (von Recklinghausen disease) is an autosomal dominant disorder that affects connective tissue. The most common type is NF-1, and is associated with primary skeletal disorders such as scoliosis, cortical thinning and pseudarthrosis of the tibia. It is the result of an abnormality on chromosome 17, and is also associated with: C afà au lait spots Neurofibromas Axillary or inguinal freckling Iris hamartomata (Lisch nodules) Scoliosis in NF-1 can occur in 2 patterns. The first is similar to idiopathic scoliosis. The second, or dystrophic type is marked by short, sharper deformities, scalloping of the vertebral bodies, rib pencilling, enlarged foramina and severe apical vertebral body rotation. Some authors have demonstrated that curves characterized as idiopathic in childhood can take on dystrophic characteristics later in life and progress rapidly. Treatment is usually surgical.
Question 2:
A 3-year-old boy is referred by the pediatrician for neck stiffness. He has a mild hearing loss, but is otherwise healthy. On examination, his neck is rather short, and he has limitation of lateral rotation and bending, but flexion and extension are normal. There are no palpable bands in his neck. The anteroposterior and lateral cervical spine films ordered by the pediatrician show a congenital fusion of cervical vertebrae. The most likely diagnosis is:
Options:
- Klippel-Feil syndrome
- Fixed atlantoaxial rotatory subluxation
- Congenital muscular torticollis
- Arnold-C hiari malformation
- Axial neck pain
Correct Answer: Klippel-Feil syndrome
Explanation:
The classic findings of Klippel-Feil syndrome include a short neck, low posterior hairline, and decreased neck range of motion, but <50% of patients have all 3 elements of the triad. The neck motion is limited due to congenital fusion of cervical vertebrae, and the severity of cervical spine involvement usually heralds associated manifestations. Facial asymmetry, cranial nerve palsy, deafness, cardiac anomalies, and synkinesia may be detected in the involved child. It is important to differentiate congenital muscular torticollis from Klippel- Feil syndrome, because releasing the sternocleidomastoid muscle will not correct a bony deformity. Static lateral radiographs of the cervical spine may appear normal in young children, as ossification of abnormal levels has not yet occurred. Flexion/extension lateral radiographs are useful to define congenital fusions, and magnetic resonance imaging may further delineate the anatomy. It is also important to test neck motion in all planes, because flexion/extension may be normal if movement occurs through just a few spared levels. Children with Klippel-Feil syndrome rarely develop neurological symptoms as a result of the congenital cervical fusion. Later in life, they may develop neurological impairment as a result of instability or degenerative disk disease.
Question 3:
A 10-year-old boy with Down syndrome presents with his parents who have noticed that his endurance for walking seems to have decreased, and he seems clumsier. Your physical examination reveals generalized ligamentous laxity, but no other musculoskeletal abnormalities. His neurological examination is normal. His flexion/extension cervical spine radiographs are abnormal. The most likely pathophysiology is:
Options:
- Os odontoideum
- Arnold-C hiari malformation
- Klippel-Feil syndrome
- Hypothyroidism
- Transverse atlantal ligament insufficiency
Correct Answer: Transverse atlantal ligament insufficiency
Explanation:
Children with Down syndrome (trisomy 21) have a higher incidence of hypothroidism, congenital heart disease, leukemia, and slipped capital femoral epiphysis. About 20% of children with Down syndrome develop atlantoaxial instability due to incompetence of the transverse atlantal ligament, and fortunately, most are asymptomatic. Patients with Down syndrome should be screened for atlantoaxial instability with routine flexion/extension lateral cervical radiographs, especially prior to athletic participation. An atlanto-dens interval (ADI) of >5 mm should be treated with activity restriction in the absence of myelopathy. With symptoms of cervical myelopathy or an ADI >7 mm, an atlantoaxial arthrodesis is indicated.
Question 4:
A 4-week-old female infant has congenital muscular torticollis. Which of the following is not associated with this condition?
Options:
- Plagiocephaly
- C ervical spine anomalies
- Developmental dysplasia of the hips
- Sternocleidomastoid muscle fibrosis
- Difficult delivery
Correct Answer: C ervical spine anomalies
Explanation:
Congenital muscular torticollis is the most common cause of torticollis in the infant and young child. Usually, the children have a history of a breech or difficult delivery or primiparous birth. The exact etiology is unknown, but theories center around a compartment syndrome of the sternocleidomastoid muscle as a result of compression of soft tissues around the neck at the time of delivery. This results in fibrosis of the sternocleidomastoid muscle, tilting of the head to the ipsilateral side, and rotation of the head to the opposite side. Congenital muscular torticollis is associated with developmental dysplasia of the hips in up to 20% of children, so a careful examination of hip stability is mandatory, with dynamic ultrasound, if necessary. Plagiocephaly or facial and skull deformities occur in progressive torticollis within the first year of life. The association of metatarsus adductus with congenital muscular torticollis is variable in the literature. Plain radiographs of the cervical spines of children with congenital muscular torticollis are always normal, with the exception of the head tilt and rotation. Treatment initially includes stretching exercises and physical therapy early in life. Surgery (release of the muscle) is recommended if the torticollis persists after 1 year of age.
Question 5:
A 13-year old boy presents to the emergency department with back pain of 5 days duration. The pain is exacerbated by sitting or standing. He has a low- grade fever. He has pain on percussion of the lumbar spine. He has no tension signs. White blood cell count is 8000/mm3 and the erythrocyte sedimentation rate is 40 mm/hr. Plain radiographs of the spine demonstrate a narrowed intervertebral space at L3-L4. The most likely diagnosis is:
Options:
- Epidural abscess
- Diskitis
- Vertebral osteomyelitis
- Pott disease
- Iliopsoas abscess
Correct Answer: Diskitis
Explanation:
The symptoms of diskitis are often vague and insidious. This hematogenous infection of the disk space acts differently than other musculoskeletal infections. The presentation is often that of a patient with low back pain or refusal to ambulate. Fever is usually low or absent. The white blood cell count is usually normal, but the erythrocyte sedimentation rate or C -reactive protein levels may be elevated. Blood cultures are frequently negative. Radiographs of the spine may be normal initially, but may show intervertebral disk space narrowing or end plate irregularities. Bone scan and magnetic resonance imaging are also helpful in the diagnosis. Treatment is usually conservative, and outcomes are aided by the fact that this condition is usually self-limiting. Rest and immobilization provide symptomatic relief, and many authors favor intravenous antibiotics. After an initial response in 72 hours or less, the patient can be switched to oral antibiotics for 3 to 5 weeks. A biopsy is indicated if the patient does not improve quickly, or if a tumor or abscess formation is suspected. Patients with vertebral osteomyelitis or abscesses are typically more ill- appearing, have high fevers and white blood cell counts, and a markedly elevated erythrocyte sedimentation rate. Furthermore, a patient with an epidural abscess may have neurological symptoms or a positive straight leg raising test, due to nerve root irritation or spinal cord compression.
Question 6:
An 11-year-old boy sustains a fall while jumping on a trampoline. He has moderate back pain, an L-5 radiculopathy, and weakness of the right extensor hallucis longus. Radiographs and a computerized tomography scan of the lumbar spine demonstrate a slipped vertebral apophysis. The recommended treatment is:
Options:
- Laminectomy and excision of annulus and vertebral bony margin
- Bed rest
- Thoracolumbosacral orthosis
- Physical therapy
- Spinal traction
Correct Answer: Laminectomy and excision of annulus and vertebral bony margin
Explanation:
This patient has a slipped vertebral apophysis as a result of trauma. This is analagous to a Salter-Harris type II fracture. A portion of the apophysis and annulus slip posteriorly and may impinge on the exiting nerve root. These usually do not resolve spontaneously or improve with conservative therapy, and excision is indicated. The disk fragments and retropulsed bone must be removed from the canal with a laminectomy for exposure.
Question 7:
Appropriate treatment of a nondisplaced Jefferson fracture is:
Options:
- Hard cervical orthosis
- Halo vest
- Soft collar
- Posterior surgical stabilization
- Nerve treatment necessary
Correct Answer: Hard cervical orthosis
Explanation:
Fractures involving the C 1 or atlas are generally caused by axial compression with either a flexion or extension force. Generally, fractures involving the C 1 consist of multiple fragments. The classical Jefferson fracture is a 4-part fracture of the atlas and can be unstable. However, in this situation, a nondisplaced fracture represents a relatively stable injury. An open-mouth odontoid anteroposterior radiograph is frequently useful to evaluate unstable patterns. An unstable fracture typically has displacement of the lateral masses greater than 8 mm. If displacement of this amount occurs, generally, the transverse ligament has been disrupted and should be treated by halo vest immobilization. In this nondisplaced situation, a hard Philadelphia collar is the most appropriate form of treatment.
Question 8:
The American Spinal Injury Association has developed a classification of spinal cord injuries. Using this classification system, an Asia C injury is best described as:
Options:
- C omplete motor loss with incomplete sensation
- C omplete motor loss with complete sensation loss
- Incomplete motor loss with some preservation of motor function with groups with less then grade 3 strength
- Incomplete motor loss with normal bladder function
- Incomplete motor loss with 4+ strength and patchy sensation
Correct Answer: C omplete motor loss with incomplete sensation
Explanation:
Asia C is an incomplete spinal cord injury with reservation of motor function with < grade 3 motor strength.C orrect Answer: Incomplete motor loss with some preservation of motor function with groups with less then grade 3 strength
Question 9:
Which of the following incomplete spinal cord injury syndromes has the most potential for recovery:
Options:
- Anterior cord syndrome
- C entral cord syndrome
- Brown-Sequard syndrome
- Posterior cord syndrome
- Pyramidal syndrome
Correct Answer: Brown-Sequard syndrome
Explanation:
Brown-Sequard syndrome is described as ipsilateral loss of motor function and contralateral loss of pain and temperature sensation. This syndrome is caused by penetrating injuries. Generally < 90% of patient who have this injury will recover ambulation.
Question 10:
A 6-year-old boy has neck pain and stiffness following an upper respiratory tract infection. He presented with his head tilted to the right and turned to the left 3 weeks ago, but a soft cervical collar has not been beneficial. There is no known history of trauma. A computerized tomography scan shows rotatory subluxation of C 1 on C 2. The next step in the treatment of this child is:
Options:
- Observation
- Open reduction and C 1-C 2 fusion through an anterior approach
- In situ C 1-C 2 fusion posteriorly
- C ervical traction
- Hard cervical collar
Correct Answer: C ervical traction
Explanation:
This child has torticollis as sequelae of an upper respiratory infection (Grisel syndrome) and rotatory subluxation (fixation) of C 1 on C 2. Other causes of torticollis include congenital muscular torticollis, neurogenic causes, Sandifer syndrome, Klippel-Feil syndrome, juvenile rheumatoid arthritis, and trauma. The common thread is that all of the etiologies appear to weaken, through inflammation or force, the supporting soft tissue structures of the atlantoaxial articulation. The diagnosis is made by dynamic CT scan. Fielding classified atlantoaxial rotatory subluxation into 4 types: Type I is a simple rotatory displacement without an anterior shift, and is the most common type in children. Type II is rotatory fixation with anterior displacement >3 to 5 mm, and is associated with a deficiency of the transverse ligament and unilateral displacement of one lateral mass of the atlas. Type III rotatory fixation there is anterior displacement >5 mm with bilateral displacement of the lateral mass with one side displaced more than the other. This is caused by a deficiency of both the transverse ligament and secondary ligament. Type IV is rotatory fixation with posterior displacement where the dens allows posterior shift of one or both of the lateral masses, and one shifting more than the other. Types III and IV are rare but have potential for catastrophe and should be recognized to promptly initiate treatment. Children with rotatory fixation of <1 week can be treated with a soft cervical collar and rest for 1 week. Most cases resolve, but close follow-up is necessary. If spontaneous reduction does not occur after 1-2 weeks, aggressive treatment is necessary. Inpatient halter traction with judicious use of muscle relaxants and analgesics is recommended. Halo traction is necessary for reduction of longer standing (2-4 weeks) subluxation. Surgery is indicated in cases of neurological compromise, failure to achieve closed reduction, long-standing deformity (3 months or more), or recurrence following closed treatment. A Gallie-type fusion posteriorly is favored.
Question 11:
A 40-year-old victim of a car accident was complaining of anterior chest pain. An x-ray of the chest showed no widening of the mediastinum and absence of pneumothorax. Lateral C XR revealed a fractured sternum with the proximal part of the fracture displaced posteriorly. Which of the following is the next step in the management of this patient?
Options:
- Arterial blood gas
- Aortogram
- C hest bandage for the fractured sternum
- C omputed Tomography of the chest
- Lateral x-ray of the thoracic spine with the patient supine
Correct Answer: Arterial blood gas
Explanation:
N/AC orrect Answer: Lateral x-ray of the thoracic spine with the patient supine
Question 12:
A 42-year-old male has a history of 6 months of pain in the lower thoracic region. Recently, the patient developed weakness in the right lower extremity, bladder and bowel movement. Plain x-rays were normal, but an magnetic resonance imaging (MRI) showed a posterolateral thoracic disk herniation at the level of T10-T11 (Slides 1 and 2). Which of the following is the best suggested treatment?
Options:
- Bed rest
- Thoraco-lumbar orthosis
- Laminectomy and decompression
- Diskectomy through thoracotomy or costotransverectomy
- Thoracotomy, vertebractomy, strut graft and internal fixation
Correct Answer: Diskectomy through thoracotomy or costotransverectomy
Explanation:
Conservative treatment should be considered for patients without major neurologic deficits. Posterior laminectomy and decompression provides inadequate exposure of the herniated Disk. Vertebractomy, strut bone graft and instrumentation are no necessary. Thoracotomy and costotransversectomy are commonly used for disk herniations at the levels of T4-T12.
Question 13:
The patient's clinical diagnosis is degenerative spondylolithesis. In what patient population is this condition most commonly symptomatic?
Options:
- Pre-teen males
- Females 40- to 70-years-old
- Males over 70-years-old
- Females 20- to 30-years-old
Correct Answer: Females 40- to 70-years-old
Explanation:
Degenerative spondylolithesis is most frequently symptomatic in the 40- to 70-year-old age range and is six times more common in females than in males. This population appears to have enough disc degeneration and motion to become symptomatic, whereas the older population tend to have acquired enough ankylosis at the level to prevent instability symptoms.
Question 14:
The patient was diagnosed with spinal stenosis of the lumbosacral spine. In addition to educating the patient about his condition, the most appropriate initial treatment is:
Options:
- Walking program
- Nonsteroidal anti-inflammatory drugs
- Lumbar traction
- Spinal decompression and fusion
Correct Answer: Nonsteroidal anti-inflammatory drugs
Explanation:
Initial treatment begins with patient education, a physical therapy regime (gentle conditioning exercises), judicious activity change, and sometimes spinal support with a corset or light-weight brace. Anti-inflammatory nonsteroidal drugs provide some relief of symptoms for many patients.
Question 15:
The biggest contribution to lumbar lordosis:
Options:
- Occurs mostly within the disk spaces
- Occurs mostly within the vertebral bodies
- Is normally 70°
- Decreases with increasing age
- Can be visualized best on an anteroposterior plain radiograph
Correct Answer: Occurs mostly within the disk spaces
Explanation:
Most of the lumbar lordosis occurs within the disk spaces and not within the vertebral bodies. Normal lumbar lordosis is between 30°to 50°, increases with age, and is best visualized on a lateral plain radiograph.
Question 16:
The superior aspect of the iliac crest often bisects this midline spinal structure:
Options:
- L2/L3 disk space
- L3 vertebral body
- L3/L4 disk space
- L4/L5 disk space
- L5/S1 disk space
Correct Answer: L4/L5 disk space
Explanation:
The L4/L5 intervertebral disk space is located by placing your fingers at the top of a patient's iliac crests, while allowing your thumbs to meet at the midline of the spine between the palpable L4 and L5 spinous processes.
Question 17:
C ertain physical examination maneuvers attempt to elicit tension signs. When used in the supine position, these maneuvers are designed to apply stretch or tension on the sciatic nerve and any inflamed nerve root against a herniated lumbar disk. Which of the following physical examination tests is not a tension sign maneuver:
Options:
- Lasegue sign
- McMurray sign
- Bowstring sign
- The sitting room test
- C ontralateral straight-leg raising test
Correct Answer: McMurray sign
Explanation:
McMurray sign is used to detect a torn meniscus in the knee and will have minimal effect on the sciatic nerve. Lasegue sign is the classic straight-leg raising test. The bowstring sign is a variation of the straight-leg raising test performed with the knee in a flexed position. Digital pressure is then applied over the popliteal space in an attempt to reproduce the tension sign. The sitting room test is performed with the patient in a sitting position. The hip remains flexed at 90° while the examiner extends the ipsilateral knee. The contralateral straight-leg raising test is performed in the same manner as the straight-leg raising test except the contralateral, or nonpainful, leg is raised.
Question 18:
When palpating the sacral triangle in the posterior aspect of a patient's lower back, if gaps are present between the spinous processes or no lumbar or sacral bony prominences are detected, this is suggestive of:
Options:
- Spina bifida
- Gibbus deformity
- Scoliosis
- Becs de perroquet
Correct Answer: Spina bifida
Explanation:
When palpating the lumbosacral area (sacral triangle), if palpable gaps are present between the spinous processes or there is an absence of lumbar and/or sacral bony prominences, this is suggestive of spina bifida. A Gibbus deformity is characterized by a sharp kyphosis and is often found in the thoracic spine. Scoliosis is identified by a lateral curvature of the spine A palpable "step-off" of one spinous process relative to the next would be suggestive of a spondylolisthesis. Becs de perroquet is a radiographic feature associated with tuberculosis of the lumbar spine in which bony bridges form across the sides of two adjacent vertebrae.
Question 19:
Which of the following is not a routinely used imaging technique for the evaluation of lumbar disk disease:
Options:
- Myelography
- C omputer tomography
- Magnetic resonance imaging (MRI)
- Positron emission tomography (PET)
- Bone scan
Correct Answer: Positron emission tomography (PET)
Explanation:
Positron emission tomography (PET) is a technique that measures brain activity through positron emission from radiolabled glucose. Myelography is an invasive procedure with radio-opaque dye placed into subarachnoid space. It aids in the detection of neural compressive lesions. Computer tomography alone offers better visualization of bony lesions, foraminal spinal stenosis, and lateral disk herniations when compared to plain myelography. C omputer tomography is often combined with myelography. Magnetic resonance imaging (MRI) has an advantage over CAT because it detects soft tissue pathologies, including improved spinal cord imaging in the detection of intraspinal tumors. MRI also examines the entire spine. Bone scanning is a nonspecific but sensitive test. It is useful in detecting neoplastic, infectious, traumatic, and/or arthritic problems in the spine.
Question 20:
A 28-year-old woman complains of pain and numbness in her lower legs bilaterally for approximately 2 months following strenuous moving of furniture. She now states that she has not voided in the past 48 hours and that her abdomen area is markedly distended. Which is the most likely causative lesion of the patient's symptoms:
Options:
- C auda equina syndrome
- Far-lateral disk herniation
- Posterolateral disk herniation
- Spinal stenosis
- Muscle spasms of the lower back
Correct Answer: C auda equina syndrome
Explanation:
This patient's symptoms are most consistent with cauda equina syndrome. This surgical emergency can present with bowel or bladder dysfunction, and bilateral lower extremity symptoms are also often present.
