Lumbar and Thoracic Degenerative Disk Disease Flashcards
Degenerative disk disease in lumbar spine consists of age and wear related decrease in proteoglycan content of the disk, disk desiccation, tear in the annulus fibrosus, disk fibrosis, disk resorption, loss of disk space height, and osteophytes formation. What is the most powerful determinant in developing degenerative disk disease?
● A. Genetic influence and possibly other unidentified factors
● B. Cumulative effects of micro- and macrotraumas
● C. Osteoporosis
● D. Cigarette smoking
● E. Stresses on the spine like excess body weight and loss of muscle tone (primarily abdominal and paraspinal muscles)
A. Genetic influence and possibly other unidentified factors
Lumbar spinal stenosis is most common at L4–L5 and then at L3–L4 level. Symptomatic stenosis typically produces neurogenic claudication which classically is gradually progressive back and/or leg pain exacerbated by standing or walking that is relieved by sitting, lying down, or flexing at the waist. It is differentiated with vascular claudication which is usually relieved at rest regardless of position. Which of the following are contributing factors for symptomatic lumbar spinal stenosis?
● A. Congenital narrow spinal canal (short pedicle syndrome)
● B. Hypertrophy of facets and ligamentum flavum abnormalities like hypertrophy, ossification, and infolding (buckling) caused by loss of disk space height
● C. Disk bulging, herniation, collapse, and osteophyte formation
● D. Malalignment of vertebral bodies like spondylolisthesis including anterolisthesis, retrolisthesis, and olisthesis
● E. All of the above
E. All of the above
Lateral recess is the gutter alongside the pedicle, and narrowing of this space causes compression on nerve root en passant (e.g., in case of L4–L5 lateral recess narrowing, L5 nerve root will be involved) while foraminal stenosis (which can be caused by lateral disk herniation, facet hypertrophy, spondyl-
olisthesis, or disk space collapse) causes compression on the exiting nerve root as in above case L4 nerve root. Foraminal stenosis also causes loss of inverted teardrop appearance of the foramen on T1WI or T2WI sagittal MRI images. Which of the following is correct regarding boundaries of lateral recess?
● A. It is bordered anteriorly by the vertebral body
● B. It is bordered laterally by the pedicle
● C. It is bordered posteriorly by the superior articular facet of the inferior vertebral body
● D. All of the above
D. All of the above
Neurogenic claudication (NC) is thought to arise from ischemia of the lumbosacral nerve root, as a result from increased metabolic demand from exercise together with vascular compromise of the nerve root due to pressure from the surrounding structures. Following are the differences between neurogenic claudication and vascular claudication (VC) except?
● A. Distribution of pain in case of NC is dermatomal, while in case of VC, it is sclerotomal (in the distribution of muscle group)
● B. Sensory loss is in the distribution of dermatome in case of NC, while it is stocking distribution in case of VC
● C. NC pain is relieved with rest slowly often in 30 minutes, while VC pain is relieved almost immediately after taking rest
● D. Claudication distance in case of NC is variable from day to day, while it is constant in case of VC
● E. Relief of pain in case of NC is not positional, while in case of VC, it is positional
E. Relief of pain in case of NC is not positional, while in case of VC, it is positional
Normal AP diameter of lumbar spinal canal on lateral plain film (from spinolaminar line to posterior vertebral body) is 22 to 25 mm, while 15 mm is the lower limit of normal and less than 11 mm is severe lumbar stenosis. Normal ligamentum flavum thickness on CT is less than or equal to 4 to 5 mm. Which of the following statements is correct regarding dimensions of lateral recess on CT?
● A. Lateral recess height of 3 to 4 mm is border line (symptomatic if other lesions like disk bulge is also present)
● B. Less than 3 mm is suggestive of lateral recess syndrome
● C. Less than 2 mm is diagnostic of lateral recess syndrome
● D. All of the above
D. All of the above
In which of the Modic’s classification of vertebral endplate changes on MRI, there is high signal drop out (becomes low intensity) on STIR images?
● A. Modic type one (T1WI low intensity signal and T2WI high intensity signal)
● B. Modic type two (both T1WI and T2WI are high intensity signal)
● C. Modic type three (both T1WI and T2WI are low intensity signal)
● D. Modic type four
● E. None of the above
B. Modic type two (both T1WI and T2WI are high intensity signal)
Unenhanced lumbar MRI is the diagnostic test of choice to see central canal stenosis, lateral recess stenosis, foraminal stenosis, as well as juxtafacet cyst and increased fluid in the facet joint. Narrowed canal may assume a deltoid (also known as tricuspoid) shape with reduction of complete loss of CSF signal on T2WI. What other tests can be used as an adjunct to radiographic evaluation?
● A. Ankle brachial index and bicycle test to rule out vascular claudication
● B. EMG with NCV to exclude peripheral neuropathy when index of suspicion is high
● C. Bone density evaluation to see osteopenia or osteoporosis
● D. Facet blocks
● E. All of the above
E. All of the above
Spondylolisthesis is the displacement (subluxation) of one vertebral body on another in any direction. Most commonly the superior vertebral body is anterior to the posterior one. It is most common at L5 on S1, the next most common is at L4–L5. On axial MRI, it may look like a herniated disk which has
been termed as a pseudodisk. Which of the following are the types of spondylolisthesis?
● A. Type 1 is dysplastic which is also called as congenital
● B. Type 2 is isthmic which is further subdivided as lytic, elongated, and acute fracture of pars
● C. Type 3 is degenerative
● D. Type 4 is traumatic
● E. Type 5 is pathologic
● F. All of the above
F. All of the above
Surgical intervention in case of spondylolisthesis is done when symptoms become severe in spite of conservative management. The goals of surgery are pain relief, halting progression of symptoms, and possibly reversal of some existing neurologic deficit. Surgical options include posterior decompression with or without fusion which may include posterior lumbar interbody fusion or transforaminal lumbar interbody fusion. Which of the following are the situations where a fusion should be considered
in addition to direct or indirect decompression of the nerves?
● A. Spondylolisthesis (especially grade more than 1)
● B. Symptomatic sagittal imbalance or degenerative scoliosis
● C. Dynamic instability on flexion/extension lateral lumbar spine X-rays
● D. Expectation that decompression will destabilize the spine
● E. Multiple recurrent herniated disk
● F. All of the above
F. All of the above
Gill procedures include which of the following?
● A. Radical decompression of nerve root including removal of the loose posterior elements and total facetectomy
● B. Posterolateral or interbody fusion
● C. Fusion rate may be enhanced with the use of internal fixation, for example, transpedicular screw rod fixation
● D. All of the above
D. All of the above
What is the most powerful determinant in developing degenerative spine disease (DSD)?
● A. Genetic influence
● B. Cumulative effects of micro-trauma and macro-trauma to the spine
● C. Osteoporosis
● D. Cigarette smoking
● E. Excess body weight
A. Genetic influence
Lumbar spinal stenosis is caused by hypertrophy of facets and ligamentum flavum and may be exacerbated by spondylolisthesis. It occurs most commonly at which level?
● A. L1–L2
● B. L2–L3
● C. L3–L4
● D. L4–L5
● E. L5–S
D. L4–L5
What is the prototypical symptom of lumbar spinal stenosis (LSS)?
● A. Neurogenic claudication
● B. LE spasticity
● C. Sphincter disturbance
● D. Low back ache
● E. Weakness of LE
A. Neurogenic claudication
What is the clinical feature distinguishing neurogenic claudication from vascular claudication?
● A. Pain in the distribution of muscle group with common vascular supply (sclerotomal)
● B. Relief with rest is slow (often > 30 mins), variable, usually positional (stooped posture or sitting often required)
● C. Claudicating distance is constant every day
● D. Sensory loss in stocking distribution
● E. Reliably reproduced with fixed amount of exercise
B. Relief with rest is slow (often > 30 mins), variable, usually positional (stooped posture or sitting often required)
What is the normal AP diameter of lumbar spinal canal on lateral plain film?
● A. 11 to 15 mm
● B. 15 to 18 mm
● C. 18 to 22 mm
● D. 22 to 25 mm
● E. 25 to 28 mm
D. 22 to 25 mm
