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Question 1

A patient with severe coughing is admitted to the hospital and has tuberculosis of the right lung, with extension to the thoracic vertebral bodies of T6 and T7, producing a “gibbus deformity.” What condition is confirmed by radiograph examination?

Answer 1

Hyperkyphosis is characterized by a “hunch-back” due to an abnormal increase in curvature of the thoracic region of the vertebral column.

Question 2

A patient has compression fractures to verebrae L4 and L5. Which parts of the vertebrae are most likely fractured in this patient?

Answer 2

A crush fracture is characterized by compression of the entire vertebral body.

Question 3

A patient has spinal canal stenosis syndrome. Which ligament is hypertrophied?

Answer 3

The ligamentum flavum connects the laminae of 2 adjacent vertebrae and forms the posterior wall of the vertebral canal. It is 1 of 2 ligaments in direct contact with the vertebral foramen (the other being the posterior longitudinal ligament)

Question 4

A patient has an injury to the dorsal surface of the neck and a fracture of the medial border of the right scapula. The patient presents with the scapula retracted laterally on the affected side. Which nerve is injured?

Answer 4

The dorsal scapular nerve (from ventral ramus of C5) is responsible for innervating the rhomboids major and minor, which are responsible for retraction of the scapula.

Question 5

A 3-year old boy needs a lumbar puncture. Which vertebral level is the most appropriate for the lumbar puncture?

Answer 5

A lumbar puncture takes CSF from the lumbar cistern (subarachnoid space) between L4 and L5.

The spinal cord typically ends at L1 to L2, and the dural sac ends at S2. In children, the cord ends more caudally.

Question 6

When a lumbar puncture is perfromed, which external landmark is the most reliable to determine the position of the L4 vertebral spine?

Answer 6

The highest points of the iliac crests are used as a landmark for locating the position of L4 to L5 for a lumbar puncture; they are identified and traced medially toward the vertebral column (Tuffier’s line).

Question 7

A man presents with severe neck pain after a whiplas injury sustained which his car was struck from behind. Examinations reveals trauma to the ligament lying on the anterior surface of the cervical vertebral bodies–which ligament is this?

Answer 7

The anterior longitudinal ligament lies anterior to the vertebral bodies along the vertebral column.

Question 8

A man complains of severe back pain. Examination shows compression of nerve elements at the intervertebral foramen between L5 and S1. Which structure is responsible for this space-occupying lesion?

Answer 8

Compression of nerves at the intervertebral foramen indicates a disc herniation, which is characterized by protrusion of the nucleus pulposus through the anulus fibrosus posteriolaterally into the spinal canal or intervertebral formamen.

Question 9

A 1-year old girl has dimpling of the skin in the midline of the lumbar region with a tuft of hair growing over the dimple. What is this condition called?

Answer 9

Spina bifida is a developmental condition resulting from incomplete fusion of the vertebral arches within the lumbar region. Spina bifida occulta commonly presents asymptomatically with midline, lumbar, cutaneous stigmata such as a tuft of hair and a small dimple.

Question 10

Answer 10

Question 11

Answer 11

Question 12

(1.17) In the event of intervertebral disc herniation in the cervical region, which ligament is in an anatomic position to protect the spinal cord from direct compression?

Answer 12

The posterior longitudinal ligament is the only ligament spanning the posterior aspect of the vertebral bodies and intervertebral discs.

Question 13

(1.18) In adults, the spinal cord usually terminates at the disc between which vertebral levels?

Answer 13

L1 and L2

Question 14

(1.21) A woman is diagnosed with stenosis of the cervical vertebral canal. A laminectomy of 2 vertebrae is performed. Which ligaments will most likely also be removed?

Answer 14

The ligamentum flavum is 1 of the 2 ligaments found in the vertebral canal (the other being the PLL) and is adherent to the ant. aspect of the vertebral arches and often greatly thickened in spinal pathology.

Question 15

(1.22) A pregnant woman is in labor. A caudal anesthetic is administered via the sacral hiatus. Into which space in the sacral canal is the anesthetic placed?

Answer 15

The spinal epidural space is found superficially to the dura mater. It is a fat-filled space extending from C1 to the sacrum.

The subarachnoid space is a true space containing CSF.

Question 16

(1.23) A lumbar puncture is performed on a patient. Which ligaments were most likely penetrated by the needle?

Answer 16

The supraspinous ligament extends between spinous processes on the dorsal aspect of the vertebrae. The needle will bypass this structure first, followed by the ligamentum flavum.

Question 17

(1.24) A patient damaged the tip of the transverse process of the third cervical vertebra, with a significantly large pulsating hematoma. Which artery is most likely to have been damaged?

Answer 17

The vertebral arteries run through the transverse foramina of cervical vertebrae C6 through C1 and are therefore most closely associated with injury to the transverse processes.

Question 18

(1.25) A patient has an abnormally increased convexity to his thoracic curvature resulting from osteoporosis. Which condition does he have?

Answer 18

Hyperkyphosis is an increased primary curvature of the spinal column. This curvature is associated with thoracic and sacral regions and is most likely this patient’s condition.

Question 19

(1.27) A man was in an accident that resulted in compression of his spinal cord by the dens (odontoid process) of the axis, with resulting quadriplegia. Which ligaments were torn?

Answer 19

The transverse ligament of the atlas anchors the dens laterally to prevent posterior displacement of the dens.

Question 20

(1.31) Examination reveals bleeding of the internal vertebral venous plexus (of Batson), resulting in a large hematoma. In what space has the blood most likely accumulated?

Answer 20

The internal vertebral plexus (of Batson) surrounds the dura mater in the spinal epidural space; hence the bleeding would cause the hematoma in that space.

The subarachnoid space, containing the CSF, is located between pia and arachnoid mater.

Question 21

(1.33) A man suffered a lower back strain. MRI reveals injury to the muscles responsible for extending and laterally bending the trunk. What arteries provide blood supply for these muscles?

Answer 21

Posterior intercostal arteries supply the deep back muscles, which are responsible for extending and laterally bending the trunk.

The thoracodorsal artery supplies the lat. dorsi.

Question 22

(1.34) Contrast the atlanto-axial vs. atlanto-occipital joints

Answer 22

• atlanto-axial = rotation of the head (saying “no” movements)
• atlanto-occipital = flexion and extension (saying “yes” movements)

Question 23

(1.38) A man shatters the lateral border of his right scapula. Physical examination reveals difficulty laterally rotating the arm. Which muscle is most probably injured?

Answer 23

The infraspinatus is responsible for lateral rotation of the humerus (along with the teres minor).

The teres major is responsible for adduction and medial rotation of the humerus.

The lat. dorsi is responsible for adduction, extension and medial rotation of the humerus.

The trapezius is an elevator of the scaula and rotates the scapula during abduction of the humerus above the horizontal plane.

The supraspinatus is responsible for initiating abduction (0-15 degrees).

Question 24

(1.42) A patient has signs of conus medullaris syndrome. At which vertebral levels is the tumor located?

Answer 24

The conus medullaris is usually located at the L1 to L2 vertebral levels.

Question 25

(1.43) A 3-day olf infant has protrusion of his spinal cord and meninges from a defect in the lower back. What term describes this congenital anomaly?

Answer 25

Because the meninges and spinal cord are included in the protrusion, the patient’s condition is a classic presentation of spina bifida with myelomeningocele.

If the protrusion contains only meninges but no CNS tissue, it is known as spina bifida with meningocele.

Question 26

(1.48) A man curshed his spinal cord at vertebral level C6. Which muscles will most likely be paralyzed?

Answer 26

All of the spinal nerves from C6 and below will be affected. The deltoid will be affected because its nerve supply is from the axillary nerve (C5, C6).

The lat. dorsi would also be affected because its nerve supply is from the thoracodorsal nerve (C6, C7, C8)

Question 27

(1.50) A patient has a soft lump above the buttocks. The lump is located just superior to the iliac crest unilaterally on the left side. The protrusion is deep to the skin and pliable to the touch. What is the most probably diagnosis?

Answer 27

The lumbar triangle (of Petit) is bordered medially by the lat. dorsi, laterally by the external abdoinal oblique and inferiorly by the iliac crest. The floor of Petit’s triangle is formed by the internal abdominal oblique and is a possible site of herniation.

An indirect inguinal hernia is located in the inguinal canal of the ant. abdominal wall.

A direct inguinal hernia is located in Hesselbach’s triangle of the ant. abdominal wall.

A femoral hernia occurs below the inguinal ligament.

Question 28

(1.67) The intervertebral disc is made of what type of cartilage that gives it tensile strength?

Answer 28

Fibrous cartilage

Question 29

(1.68) What is the embryologic origin of the anulus fibrosus and nucleus pulposus, respectively?

Answer 29

nucleus pulposus = notochord

anulus fibrosus = sclerotome

Question 30

(1.70) A man has vertebral fractures in the cervical region impinging the dorsal primary rami of the same levels. Which muscles are affected?

Answer 30

Semispinalis capitis (and other deep back muscles) are supplied by the dorsal rami.

The rhomboid major and minor are innervated by the ventral primary rami of the dorsal scapular nerve.

The levator scapulae is innervated by branches of C4 and C5, as well as from branches of dorsal scapular nerve.

The lat. dorsi is innervated by thoracodorsal nerve.

Question 31

(1.75) A man was in an accident that resulted in the dens crushing the spinal cord. Which ligament was torn for the dens to crush the spinal cord?

Answer 31

The transverse ligament of the atlas anchors the dens laterally to prevent posterior displacement of the dens.

The ALL runs on the ant. aspect of the vertebrae and is not affected.

The ligamentum flavum is found on the posterior aspect of the vertebral canal and does not contact the anteriorly placed dens.

Question 32

(1.97) A surgeon noticed that the posterior roots were compressed at T9-T9 due to a space-occupying lesion. Which artery was compressed by this lesion?

Answer 32

The radicular arteries are branches of the segmental spinal arteries. They occur at every vertebral level and follow and provide blood supply to the ant. and post. roots. A space occupying lesion that compresses the post. roots will also compress the arteries that supply them.

The segmental spinal arteries are feeder arteries that reinforce the blood supply to the spinal cord and arise from the vertebral and deep cervical arteries.