Lecture 4 CCQ's (Back and Spinal Cord)

Question 1

Question 1: A 23-year-old jockey falls from her horse and complains of headache, backache, and weakness. Radiologic examination would reveal blood in which of the following spaces if the internal vertebral venous plexus was ruptured?

a. Space deep to the pia mater
b. Space between the arachnoid and dura maters
c. Subdural space
d. Epidural space
e. Subarachnoid space

Answer 1

Question 1: A 23-year-old jockey falls from her horse and complains of headache, backache, and weakness. Radiologic examination would reveal blood in which of the following spaces if the internal vertebral venous plexus was ruptured?

a. Space deep to the pia mater - The space deep to the pia mater contains the spinal cord and blood vessels.
b. Space between the arachnoid and dura maters - The space between the arachnoid and dura mater is the subdural space, which contains a film of fluid.
c. Subdural space - The subdural space is a potential space between the arachnoid and dura mater, and traversed by cerebral vein before draining into dural venous sinuses.

d. Epidural space -The epidural space is the space between the vertebral canal and the dura mater, which contains the internal vertebral venous plexus.

e. Subarachnoid space - The subarachnoid space is a space between arachnoid and pia maters, which contains cerebrospinal fluid (CSF).

Question 2

Question 2: A 39-year-old woman with headaches presents to her primary care physician with a possible herniated disk. Her magnetic resonance imaging (MRI) scan reveals that the posterolateral protrusion of the intervertebral disk between L4 and L5 vertebrae. Which of the following nerves is most likely compressed by the herniation?

a. Third lumbar
b. Fourth lumbar
c. Fifth lumbar
d. First sacral
e. Second sacral

Answer 2

Question 2: A 39-year-old woman with headaches presents to her primary care physician with a possible herniated disk. Her magnetic resonance imaging (MRI) scan reveals that the posterolateral protrusion of the intervertebral disk between L4 and L5 vertebrae. Which of the following nerves is most likely compressed by the herniation?

a. Third lumbar
b. Fourth lumbar

c. Fifth lumbar

• A posterolateral herniation of the intervertebral disk at disk level L4 to L5 affects the fifth lumbar nerve root but rarely affects the fourth lumbar nerve root because of a progressive descending obliquity of the fourth and fifth lumbar nerve roots. The first seven cervical nerves exit above the corresponding vertebra, and the eighth cervical nerve exits below the seventh cervical vertebra because there are eight cervical nerves but only seven cervical vertebrae. The rest of the spinal nerves exit below their corresponding vertebrae.
  d. First sacral
  e. Second sacral

Question 3

Question 3: After a 26-year-old man’s car was broadsided by a large truck, he is brought to the emergency department with multiple fractures of the transverse processes of the cervical vertebrae. Which of the following muscles will most likely be affected?

a. Trapezius
b. Levator scapulae
c. Rhomboid major
d. Serratus posterior superior
e. Rectus capitis posterior major

Answer 3

Question 3: After a 26-year-old man’s car was broadsided by a large truck, he is brought to the emergency department with multiple fractures of the transverse processes of the cervical vertebrae. Which of the following muscles will most likely be affected?

a. Trapezius

b. Levator scapulae

• The levator scapulae arise from the transverse processes of the upper cervical vertebrae and inserts on the medial border of the scapula.
  c. Rhomboid major
  d. Serratus posterior superior
• The serratus posterior superior muscle arises by a thin and broad aponeurosis from the lower part of the ligamentum nuchae, from the spinous processes of the seventh cervical and upper two or three thoracic vertebrae and from the supraspinal ligament.
  e. Rectus capitis posterior major

Question 4

Question 4: A 27-year-old mountain climber falls from a steep rock wall and is brought to the emergency department. His physical examination and CT reveal dislocation fracture of the upper thoracic vertebrae. The body of the T4 vertebra normally articulates with which of the following parts of the ribs?

a. Head of the third rib
b. Neck of the fourth rib
c. Tubercle of the fourth rib
d. Head of the fifth rib
e. Tubercle of the fifth rib

Answer 4

Question 4: A 27-year-old mountain climber falls from a steep rock wall and is brought to the emergency department. His physical examination and CT reveal dislocation fracture of the upper thoracic vertebrae. The body of the T4 vertebra normally articulates with which of the following parts of the ribs?

a. Head of the third rib
b. Neck of the fourth rib
c. Tubercle of the fourth rib
* The transverse process of the vertebra articulates with the tubercle of the corresponding rib. Therefore, the transverse process of vertebra T4 articulates with the tubercle of the fourth rib.

d. Head of the fifth rib

• The body of vertebra T4 articulates with the heads of the fourth and fifth ribs.
  e. Tubercle of the fifth rib

Question 5

Question 5: A patient presents with intense pain during inspiration over the lateral right rib cage at rib #7. Auscultation reveals a rubbing noise directly over the painful region each time the patient takes an inspiration. Inflammation of the parietal pleura is diagnosed. This pain is carried by:

a. somatic afferent fibers in the ventral ramus
b. visceral afferent fibers in the ventral ramus
c. somatic afferent fibers in the dorsal ramus
d. visceral afferent fibers in the dorsal ramus
e. visceral afferent fibers in the right vagus nerve

Answer 5

Question 5: A patient presents with intense pain during inspiration over the lateral right rib cage at rib #7. Auscultation reveals a rubbing noise directly over the painful region each time the patient takes an inspiration. Inflammation of the parietal pleura is diagnosed. This pain is carried by:

a. somatic afferent fibers in the ventral ramus

• The somatic afferent fibers in the ventral ramus carry sensory information from the muscle, joints, and skin of the lateral walls and the extremities. Generally responsible for sensory function from somatic tissues, like parietal pleura through sensory afferent fibers in the ventral ramus.
  b. visceral afferent fibers in the ventral ramus
• The visceral afferent fibers in the ventral ramus carry sensory information (usually pain or reflex sensations) from the internal organs, glands, and blood vessels to the CNS. These fibers are considered to be part of the autonomic nervous system, although not classified as either sympathetic and parasympathetic.
  c. somatic afferent fibers in the dorsal ramus
• The somatic afferent fibers in the dorsal ramus carry sensory information from from the skin and deep muscles of the back.
  d. visceral afferent fibers in the dorsal ramus
• The visceral afferent fibers in the dorsal ramus carry motor information to the deep muscles of the back. (*not sure if this is correct)
  e. visceral afferent fibers in the right vagus nerve

Question 6

Question 6: Sensation over the nipple of the breast usually implies an intact dermatome at the level of:

a. C8
b. T2
c. T4
d. T6
e. T8

Answer 6

Question 6: Sensation over the nipple of the breast usually implies an intact dermatome at the level of:

a. C8
b. T2

c. T4

• Sensation over the nipple of the breast implies that the T4 dermatome is intact.
• other dermatome to know = T10 - Umbilicus

d. T6
e. T8

Question 7

Question 7: The intrinsic muscles of the back are defined by their somatic motor innervation which is most commonly from:

a. intercostal nerves
b. dorsal rami of spinal nerves
c. ventral rami of spinal nerves
d. nerves originating in the cervical and brachial plexuses
e. recurrent meningeal nerves

Answer 7

Question 7: The intrinsic muscles of the back are defined by their somatic motor innervation which is most commonly from:

a. intercostal nerves

b. dorsal rami of spinal nerves

• The intrinsic muscles of the back receive motor innervation from the dorsal rami of spinal nerves.
  c. ventral rami of spinal nerves
  d. nerves originating in the cervical and brachial plexuses
  e. recurrent meningeal nerves

Question 8

Question 8: During a domestic dispute, a 16-year-old boy receives a deep stab wound around the superior angle of the scapula near the medial border, which injures both the dorsal scapular and spinal accessory nerves. Which of the following muscle pairings would be weakened has a result of the injury described?

a. Trapezius and serratus posterior superior
b. Rhomboid major and trapezius
c. Rhomboid minor and latissimus dorsi
d. Splenius cervicis and sternocleidomastoid
e. Levator scapulae and erector spinae

Answer 8

Question 8: During a domestic dispute, a 16-year-old boy receives a deep stab wound around the superior angle of the scapula near the medial border, which injures both the dorsal scapular and spinal accessory nerves. Which of the following muscle pairings would be weakened has a result of the injury described?

a. Trapezius and serratus posterior superior
* Trapezius is innervated by the spinal accessory nerve, but serratus posterior superior is innervated by ventral primary rami.

b. Rhomboid major and trapezius

• The dorsal scapular nerve innervates the levator scapulae and rhomboid muscles, whereas the accessory nerve innervates the trapezius and sternocleidomastoid muscles.
  c. Rhomboid minor and latissimus dorsi
  d. Splenius cervicis and sternocleidomastoid
  e. Levator scapulae and erector spinae

Question 9

Question 9: A crush injury of the vertebral column can cause the spinal cord to swell. Which structure would be trapped between the dura and the vertebral body by the swelling spinal cord?

a. Anterior longitudinal ligament
b. Alar ligament
c. Posterior longitudinal ligament
d. Cruciform ligament
e. Ligamentum nuchae

Answer 9

Question 9: A crush injury of the vertebral column can cause the spinal cord to swell. Which structure would be trapped between the dura and the vertebral body by the swelling spinal cord?

a. Anterior longitudinal ligament
* runs the entire length of the spine from the base of the skull to the sacrum. It connects the front (anterior) of the vertebral body to the front of the annulus fibrosis.
b. Alar ligament
* Axis (C2) has two alar ligaments that attach the dens of axis to the occipital condyle tubercles on the base of the skull.

c. Posterior longitudinal ligament

• The posterior longitudinal ligament interconnects the vertebral bodies and intervertebral disks posteriorly and runs anterior to the spinal cord within the vertebral canal.
  d. Cruciform ligament
• The strong ligament that lies posterior to the dens of the axis holding it against the anterior arch of the atlas; it consists primarily of the transverse ligament of the atlas that forms the cross-bar of the cross and is most important functionally, and longitudinal bands of the cruciform ligament, forming the upright or vertical beams of the cross.
  e. Ligamentum nuchae
• Although the supraspinous ligament technically stops at C7, in a sense, it continues up to the external occipital protuberance of the skull. However, anatomists refer to this section of the ligament between C7 and the external occipital protuberance as the “nuchal ligament.” The word “nuchal” refers to the nape of the neck, and this ligament helps prevent hyperflexion in the neck region.
  
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Supraspinous Ligament = this ligament attaches upon the tip of the spinous process of vertebrae C7 to the sacrum, and anteriorly, it meets the interspinous ligaments that run between the spinous process of each vertebra.