Section 4 Flashcards
Conservative treatment for low-back pain consists of therapy for first 4 to 6 weeks which includes physiotherapy, analgesics (NSAIDS), and sometimes epidural steroid injections (only in acute radiculopathy cases). Which of the following are the indications for MRI of lumbosacral spine in patients with backache with subsequent surgical treatment of identified problem appropriately?
● A. Progressive neurologic deficit (e.g., weakness)
● B. Cauda equina syndrome (includes bladder issues, saddle anesthesia)
● C. Intractable pain
● D. Failure of medical treatment
● E. All of the above
E. All of the above
Generalized displacement of disk material is defined as displacement of more than 50% or 180 degrees beyond the peripheral limit of disk space. On the other hand, herniation is localized displacement of disk material less than 50% or 180 degrees beyond the limits of the intervertebral disk space. Following statements are true regarding herniation of disk except?
● A. Focal herniation is less than 25% of disk space
● B. Broad based disk herniation is 20 to 25% of the disk herniation
● C. Schmorl’s node is not a type of disk herniation
● D. Protrusion is a type of disk herniation in which the fragment does not have a neck
● E. Extrusion is a type of disk herniation in which the fragment has a neck which is further subdivided into sequestration and migration
C. Schmorl’s node is not a type of disk herniation
Dysfunction of nerve root, which may include pain in the distribution of the nerve root or dermatomal sensory disturbances or weakness of the muscle innervated by that nerve root or hypoactive muscle reflexes of the same muscles or a combination of these, is termed as?
● A. Myelopathy
● B. Mechanical low-back pain
● C. Sciatica
● D. Radiculopathy
● E. None of the above
D. Radiculopathy
Diminished sensations over medial malleolus plus medial foot, dorsum of foot, and lateral malleolus plus lateral foot suggests L4, L5, and S1 nerve root involvement, respectively. A patient presenting with history of fever with vertebral tenderness and very limited range of spinal motion has most likely
which of the following?
● A. Spinal tumor
● B. Spinal osteoarthritis
● C. Spinal infection
● D. Spinal degenerative disease
● E. Spinal instability
C. Spinal infection
Abnormal disk morphology on MRI is loss of T2WI signal intensity (black disk), disk space collapse, Modic changes, and high intensity zones (these findings also frequently occur in asymptomatic patients). Diskography (injection of water-soluble contrast agent directly into the nucleus pulposus of the intervertebral disk) is done through the Kambin’s triangle to find out pathologic disk. Following are included in the boundaries of Kambin’s triangle except?
● A. Exiting nerve root
● B. Superior end plate of inferior vertebral body
● C. Thecal sac
● D. Inferior facet of superior vertebral body
● E. All are included in the boundaries of Kambin’s triangle
D. Inferior facet of superior vertebral body
To see dynamic instability in spine, which of the following tests is done?
● A. Flexion–extension lumbar spine X-rays
● B. Oblique X-rays
● C. Standing scoliosis X-rays
● D. Lateral spine X-rays
● E. Anteroposterior spine X-rays
A. Flexion–extension lumbar spine X-rays
Following are the advantages of CT scan over MRI except?
● A. Excellent bony detail
● B. Less expensive
● C. Outpatient evaluation
● D. More claustrophobic
● E. Faster scanning
D. More claustrophobic
Following are included in the conservative treatment of low-back pain except?
● A. Bed rest for the first 2 to 3 days, activity modification (like prolonged sitting, bending or twisting, limiting lifting objects)
● B. Exercise starting from walking in the first 2 weeks then conditioning exercises for the trunk muscles
● C. NSAIDs and paracetamol
● D. Epidural injection for short-term relief of radicular pain
● E. Oral steroids
E. Oral steroids
Which of the following is an indication of lumbar fusion in case of disk herniation?
● A. Evidence of preoperative lumbar spinal deformity or instability
● B. In patients with chronic axial low-back pain associated with radiculopathy
● C. Both A and B
● D. Spondylolisthesis grade 1 without degenerative changes
● E. None of the above
C. Both A and B
Which of the following statements is correct regarding surgical option for low-back problems?
● A. Routine HLD or initial recurrence of HLD is treated with standard diskectomy or with microdiskectomy
● B. Foraminal or far-lateral HLD can be treated with partial or total facetectomy, extra canal approach or endoscopic techniques
● C. Only lumbar spinal stenosis can be treated with simple decompression laminectomy
● D. Patients with degenerative spondylolisthesis, stenosis and radiculopathy, adult degenerative scoliosis, or instability are treated with laminectomy plus fusion
● E. All of the above
E. All of the above
Failure to satisfactorily improve low-back pain or radiculopathy following back surgery is called as failed back surgery syndrome. Which of the following are the causes of “failed back
surgery syndrome”?
● A. Incorrect initial diagnosis or continued compression caused by residual disk, epidural hematoma, or pseudomeningocele
● B. Permanent nerve root injury preoperatively or after surgery
● C. Adhesive arachnoiditis or diskitis
● D. Spondylosis
● E. All of the above
E. All of the above
Surgery for failed back syndrome is recommended only for recurrent or residual disk, instability, or a pseudomeningocele. Following are true regarding MRI study of patients after operation for back pain except?
● A. MRI study done after surgery is always done with contrast if there is no contraindication
● B. Scar enhances on post-contrast MRI study
● C. Disk does not enhance on contrast MRI
● D. MRI is done only without contrast in all cases
D. MRI is done only without contrast in all cases
Myelographic classification of arachnoiditis includes which of the following?
● A. Unilateral focal filling defect centered on nerve root sleeve adjacent to disk space
● B. Circumferential constriction around thecal sac
● C. Complete obstruction with stalactites or candle guttering
● D. Infundibular cul de sac with loss of radicular striations
● E. All of the above
E. All of the above
In disk herniation, sequestration is when the fragment has lost continuity with the disk of origin. It is a subtype of which of the following?
● A. Disk bulge
● B. Extrusion
● C. Focal
● D. Broad based
● E. Extrusion
B. Extrusion
Bone marrow edema associated with acute or subacute inflammation showing hypointensity on T1WI and hyperintensity on T2WI is what Modic type?
● A. I
● B. II
● C. III
● D. IV
● E. V
A. I
What is the score of bed-bound patients according to Oswestry disability index?
● A. 0 to 20
● B. 21 to 30
● C. 41 to 60
● D. 61 to 80
● E. 81 to 100
E. 81 to 100
Diminished Achilles reflex suggests dysfunction of root of which of the following?
● A. L2
● B. L3
● C. L4
● D. L5
● E. S1
E. S1
For diskography, injection of water-soluble contrast agent directly into the nucleus pulposus of the intervertebral disk being studied is performed by percutaneous needle access through which of the following?
● A. Pedicle
● B. Facet
● C. Kambin’s triangle
● D. Anterolateral quadrant
● E. Transforaminal
C. Kambin’s triangle
For nonspecific lower backache, for how long bed rest should be allowed?
● A. Not recommended
● B. Few hours
● C. 1 day
● D. 2 days
● E. 4 days
E. 4 days
Patients with disabling low-back pain due to two-level degenerative disease without stenosis or spondylolisthesis for ≥ 2 years with radiological evidence of disk degeneration at L4–L5, L5–S1, or both and failed best medical management, should be treated with which of the following?
● A. Thoracolumbar spinal orthosis
● B. Physical therapy
● C. Steroid
● D. Facet capsule injections
● E. Lumbar fusion
E. Lumbar fusion
First-time recurrence after diskectomy should be treated with which of the following?
● A. Same as first-time presenting herniated disk
● B. Steroids
● C. Epidural injections
● D. Physical therapy
● E. Anterior lumbar interbody fusion
A. Same as first-time presenting herniated disk
Arachnoiditis is an inflammatory condition of the lumbar nerve roots and may present as three different patterns on MRI. What is the pattern where roots adhere to meninges around periphery?
● A. Empty thecal sac
● B. Candle dripping
● C. Guttering
● D. Two central cords
● E. Central adhesion
A. Empty thecal sac
What is the myelographic classification of arachnoiditis type for unilateral focal filling defect centered on the nerve root sleeve adjacent to disk space?
● A. I
● B. II
● C. III
● D. IV
● E. V
A. I
The nerve root en passant is the nerve in lateral recess that passes through the neural foramen of the level below; for example, for L4–L5 level, it would be L5 nerve root while exiting nerve root at this level would be L4 nerve root. Most of the herniated lumbar disks are paramedian which cause compression on which of the following?
● A. Exiting nerve root
● B. Traversing nerve root
● C. Both A and B
● D. It causes thecal sac compression only
● E. None of the above
B. Traversing nerve root
Which of the following statements is incorrect regarding clinical findings with herniated lumbar disk?
● A. Symptoms may start off with back pain, which after days or weeks gradually or sometimes suddenly yields to radicular pain often with reduction of the back pain
● B. Pain is relieved upon flexing the knee and thigh (e.g., with a pillow under the knees)
● C. Remaining in any position (sitting, standing, or lying) for too long may also exacerbate the pain, sometimes necessitating position changes at intervals that range from every few minutes to 10 to 20 minutes
● D. Pain is increased with coughing, sneezing, or straining at the stool
● E. Bladder symptoms are never present with a herniated lumbar disk
E. Bladder symptoms are never present with a herniated lumbar disk
Which of the following signs are used to test tension on nerve roots in case of radiculopathy?
● A. Lasegue’s sign also known as straight leg raise sign (with the patient supine, the afflicted limb is raised by the ankle until pain is solicited, which should occur at angle less than 60 degrees and consists of leg pain or paresthesias in the distribution of pain)
● B. Cram test (with the patient supine, the symptomatic leg is raised with the knee slightly flexed and then extending the knee will produce pain similar to Lasegue’s sign)
● C. Crossed straight leg raising test also known as Fajersztajn’s sign (SLR on the painless leg cause contralateral limb pain)
● D. Femoral stretch test also known as reverse straight leg raising, which is positive with L2, L3, or L4 nerve root compression
● E. All of the above
E. All of the above
The most common level of herniated lumbar disk is L5–S1 which is 45 to 50%, the second most common level is L4–L5 which is 40 to 45%, while L3–L4 is involved in only 3 to 10% of cases. Which of the following are the symptoms caused by the S1 nerve root compression?
● A. Diminished ankle jerk (Achilles)
● B. Motor weakness of gastrocnemius causing weak plantar flexion
● C. Decreased sensations in the area of lateral malleolus and lateral foot
● D. Pain distribution in the posterior lower extremity often up to the ankle
● E. All of the above
E. All of the above
Cauda equina syndrome causes urinary retention, saddle anesthesia, significant motor weakness, and low-back pain. Following are the causes of this syndrome except?
● A. Compression of the cauda equina by massive disk herniation or tumor or free fat graft following surgery or trauma or spinal epidural hematoma
● B. Infection which may cause compression by epidural abscess or vascular compromise resulting from local septic thrombophlebitis
● C. Neuropathy caused by inflammation or ischemia
● D. Rheumatoid arthritis
● E. Ankylosing spondylitis
D. Rheumatoid arthritis
What is the desirable time of surgery after development of cauda equina syndrome?
● A. Within 48 hours
● B. Within 24 hours
● C. Within 12 hours
● D. Within 6 hours
● E. None of the above
B. Within 24 hours
Which of the following is an indication of surgery in a patient with herniated lumbar disk?
● A. Failure of nonsurgical management which is done for almost 5 to 8 weeks
● B. Patients with cauda equina syndrome
● C. Patients with progressive motor deficit
● D. Intolerable pain despite the use of adequate narcotic pain medication
● E. All of the above
E. All of the above
Surgical options for lumbar radiculopathy include transcanal approaches like standard open lumbar laminectomy and diskectomy, microdiskectomy, or sequestrectomy. Which of the following indications are utilized by proponents for intradiskal procedures like automated percutaneous lumbar diskectomy (nucleoplasty), laser disk decompression, percutaneous endoscopic lumbar diskectomy, and intradiskal endothermal therapy?
● A. Contained disk herniation
● B. Best for L4–L5 herniated disk
● C. Not recommended in severe neurologic deficit
● D. All of the above
D. All of the above
Common complications after operation for herniated lumbar disk include superficial wound infection, deep wound infection, increased motor deficit, unintended incidental durotomy, recurrent herniated lumbar disk, and postoperative urinary retention. What are the rates of superficial infection, deep infection, and incidental durotomy, respectively?
● A. 0.9 to 5%, less than 1%, and 0.3 to 13%
● B. 1%, 5%, and 13%
● C. 0.1%, 0.5%, and 0.3%
● D. None of the above
A. 0.9 to 5%, less than 1%, and 0.3 to 13%
What is the possible sequalae of dural opening?
● A. CSF leak (contained or pseudomeningocele or external, CSF fistula)
● B. Herniations of nerve roots through the opening
● C. Associated nerve root contusion, laceration, or injury to the cauda equina
● D. CSF leak may collapse thecal sac and cause bleeding from epidural blood vessels
● E. All of the above
E. All of the above
Most herniated lumbar disks occur posteriorly and slightly off to one side within which of the following?
● A. Central canal zone
● B. Foraminal zone
● C. Extraforaminal zone
● D. Far lateral zone
● E. Intravertebrally
A. Central canal zone
A herniated disk at the level of L4–L5 mostly involves root of which of the following?
● A. L3
● B. L4
● C. L5
● D. S1
● E. Filum terminale
C. L5
A foraminal herniated disk at the level of L4–L5 mostly involves root of which of the following?
● A. L3
● B. L4
● C. L5
● D. S1
● E. Filum terminale
B. L4
Which of the following is the most specific nerve root tension sign?
● A. Lasegue’s test
● B. Cross SLR
● C. Reverse SLR
● D. Hoover test
● E. FABER/Patrick test
B. Cross SLR
Which of the following is a hip motion test for sacroiliitis?
● A. Lasegue’s test
● B. Cross SLR
● C. Reverse SLR
● D. Hoover test
● E. FABER/Patrick test
E. FABER/Patrick test
What is the test used to distinguish unilateral functional weakness of iliopsoas from organic weakness using synergistic contraction of the contralateral gluteus medius?
● A. Lasegue’s test
● B. Cross SLR
● C. Reverse SLR
● D. Hoover test
● E. FABER/Patrick test
D. Hoover test
Knee jerk is diminished (Westphal’s sign) in herniated lumbar disk of which level?
● A. L2–L3
● B. L3–L4
● C. L4–L5
● D. L5–S1
● E. S1–S2
B. L3–L4
What is the most consistent finding in cauda equine syndrome?
● A. Urinary retention
● B. Saddle anesthesia
● C. Motor weakness in one limb
● D. Paraplegia
● E. Sciatica
A. Urinary retention
Which of the following is not an intradiskal procedure for lumbar radiculopathy?
● A. Chemonucleolysis
● B. Automated percutaneous lumbar diskectomy
● C. Percutaneous endoscopic intradiskal diskectomy
● D. Sequesterectomy
● E. Laser disk decompression
D. Sequesterectomy
A diabetic patient with lumbar radiculopathy was operated on and postoperatively he was blind. What is the most common cause?
● A. Anterior ischemic optic neuropathy
● B. Posterior ischemic optic neuropathy
● C. Retinal artery occlusion
● D. Cortical blindness
● E. Diabetic retinopathy
A. Anterior ischemic optic neuropathy
Extreme lateral herniated lumbar disk occurs most commonly at which level?
● A. L1–L2
● B. L2–L3
● C. L3–L4
● D. L4–L5
● E. L5–S1
D. L4–L5
Which of the following is a less well-documented sequelae of dural opening?
● A. CSF fistula
● B. Herniation of nerve roots through opening
● C. Associated nerve root contusion, laceration, or injury to the cauda equina
● D. CSF leak collapses the thecal sac and may increase blood loss from epidural bleeding
● E. Arachnoiditis
E. Arachnoiditis
Thoracic disk herniation constitutes only 0.25% of herniated disks and usually occurs at or below T8. These disks are frequently calcified. Pain and sensory disturbance are in a band-like distribution radiating anteriorly and inferiorly along the involved root’s dermatome. What is the indication of surgery
in these cases?
● A. Refractory pain
● B. Progressive myelopathy
● C. Both A and B
● D. Radiculopathy
● E. None of the above
C. Both A and B
CT should be obtained in cases of thoracic herniated disk along with noncontrast MRI of thoracic spine as most of the disks in this region are calcified. Which of the following are the options for open surgical approaches for these disks?
● A. Posterior midline laminectomy
● B. Posterolateral like lateral gutter (laminectomy plus removal of pedicle), transpedicular, costotransversectomy, and transfacet pedicle sparing
● C. Anterolateral (transthoracic) usually through the pleural space
● D. Lateral extracavitary (retrocoelomic) which is posterior to the pleural space
● E. All of the above
E. All of the above
Which of the following is a correct match of appropriate surgical approach for the given pathology?
● A. Laminectomy for posteriorly located tumor
● B. Posterolateral (transpedicular) for radicular pain with lateral disk herniation or for biopsy of tumor
● C. Lateral (costotransversectomy) for midline disk, good ipsilateral access but poor access to opposite side
● D. Transthoracic for midline lesions especially for reaching both sides of the cord
● E. All of the above
E. All of the above
To access T4–T5 disk space, which rib needs to be removed?
● A. T4
● B. T5
● C. Both A and B
● D. T5 and T6
● E. T4 and T3
B. T5
Indications of transthoracic approach for thoracic disk disease include central fragment or calcified disk, and burst fracture of thoracic spine. Following are the advantages of transthoracic approach except?
● A. It provides excellent anterior approach
● B. It causes little compromise of stability
● C. It deals easily with pathology lying posterior to the cord
● D. There is low risk of mechanical cord injury with this approach
● E. All of the above
C. It deals easily with pathology lying posterior to the cord
Which of the following statements regarding neuromonitoring during thoracic spine disease surgery is correct?
● A. It consists of MEP and SSEP
● B. It is not required for surgery at this level
● C. Injury to cord at this level cannot be prevented
● D. None of the above
A. It consists of MEP and SSEP
There is risk of injury to radicular artery which may compromise the spinal cord blood supply. How much posterior rib along with transverse process needs to be removed?
● A. 3 to 4 cm
● B. 4 to 5 cm
● C. 5 to 3 cm
● D. More than 5 cm
● E. Less than 6 cm
B. 4 to 5 cm
What skin incision can be used for costotransversectomy procedure?
● A. Curved paramedian skin incision
● B. Midline incision
● C. Both A and B
● D. T-shaped incision
● E. None of the above
C. Both A and B
What is the most common symptom after thoracic disk herniation?
● A. Pain
● B. Sensory changes
● C. Motor changes
● D. All occur at some time
D. All occur at some time
What is the percentage of occurrence pain in case of thoracic disk disease?
● A. 60%
● B. 23%
● C. 18%
● D. 8
A. 60%
About 75% of thoracic disk herniations are below which level?
● A. T6
● B. T7
● C. T8
● D. T10
● E. T12
C. T8
For thoracic spine surgery, which of the following is not a posterolateral approach?
● A. Transthoracic
● B. Lateral gutter
● C. Transpedicular
● D. Costotransversectomy
● E. Transfacet pedicle sparing
A. Transthoracic
For a central disk herniation, especially when calcified, which approach has the lowest incidence of cord injury with the best operative results?
● A. Transfacet pedicle sparing
● B. Transthoracic
● C. Lateral extracavitary approach
● D. Costotransversectomy
● E. Transpedicular approach
B. Transthoracic
Which of the following is the best approach for radicular pain with lateral disk herniation and biopsy of tumor?
● A. Transfacet pedicle sparing
● B. Transthoracic
● C. Lateral extracavitary approach
● D. Costotransversectomy
● E. Transpedicular approach
E. Transpedicular approach
During costotransversectomy, to access the vertebral body of T6, which rib needs to be removed?
● A. 5th
● B. 7th
● C. 5th and 6th
● D. 6th and 7th
● E. 5th, 6th, and 7th
D. 6th and 7th
What is the best approach for midline thoracic spine lesions, especially for reaching both sides of the cord?
● A. Laminectomy
● B. Posterolateral transpedicular
● C. Transpedicular facet sparing
● D. Costotransversectomy
● E. Transthoracic
E. Transthoracic
Which of the following statements are correct regarding cervical disk syndromes?
● A. C4–C5 herniated cervical disk is only 2%; it causes C5 nerve root compression, diminished deltoid and pectoralis reflexes, motor weakness in deltoid, and paresthesia or hypoesthesia in shoulder
● B. C5–C6 cervical disk herniation is 19%; it causes C6 nerve root compression, diminished biceps and brachioradialis reflex, forearm flexion weakness and paresthesia, and hypesthesia in upper arm, thumb, and radial forearm
● C. C6–C7 cervical disk herniation is 69%; it causes 7 nerve root compression, diminished triceps reflex, motor weakness of forearm extension (wrist drop), and paresthesia hypesthesia in fingers 2 and 3 with all finger tips
● D. C7–T1 cervical disk herniation is 10%; it causes C8 nerve root compression, diminished finger jerk, motor weakness in hand intrinsics, and paresthesia hypesthesia in fingers 4 and 5
● E. All of the above
E. All of the above
Evaluation for radiculopathy includes LMN findings which are weakness in one myotome group with atrophy and fasciculations present, sensory loss in dermatome similar to that of myotomal weakness, and eliciting muscle stretch reflexes and positive mechanical signs with reproduction of radicular
symptoms with mechanical loading of the head. Evidence of cervical cord involvement (myelopathy) is UMN findings in the lower extremity and presence of pathologic reflexes like Hoffmann’s reflex, Babinski sign, and ankle clonus. Following signs
are useful in evaluating cervical radiculopathy except?
● A. Painful limitation of neck movement in almost all herniated cervical disk patients. Neck extension usually aggravates pain when cervical disk disease is present. Some patients find relief in evaluating the arm and cupping the back or the top of the head with the hand (abduction relief sign)
● B. Lhermitte’s sign (electric shock like sensation radiating down the spine)
● C. Spurling’s sign
● D. Axial manual traction of a supine patient with 10 to 15 kg resulting in reduction or disappearance of radicular symptoms is a positive finding
● E. Positive shoulder abduction test in which lifting of hand above head causes reduction or disappearance of radicular signs
● F. Positive Hoffmann’s sign
F. Positive Hoffmann’s sign
Over 90% of patients with acute cervical radiculopathy due to cervical disk herniation can improve without surgery and regression of an extruded cervical disk has been demonstrated
radiographically. Conservative management of cervical disk includes the following except?
● A. Physical therapy which may include intermittent cervical traction (gradually escalating up to 10–15 pounds for 10–15 minutes for two to three times daily)
● B. Use of NSAIDs
● C. Use of short-course tapering steroids
● D. Trigger points injections and facet blocks have no role
● E. Epidural steroid injection (not used as often as in lumbar spine)
D. Trigger points injections and facet blocks have no role
Routine anterior approach for cervical spine surgery is usually able to access levels C3 and C7. While in patients with short thick neck, access may be even more limited. Which of the following are advantages of anterior approach over posterior approach?
● A. Safe removal of anterior osteophytes
● B. Fusion of disk space affords immobility, while there is 10% risk of immobility with extensive approach
● C. The only viable means of directly dealing with centrally herniated disk
● D. All of the above
D. All of the above
For ACDF, a horizontal skin incision in mediolateral direction is made. C5–C6 disk is at the level of which of the following?
● A. Hyoid bone
● B. Thyroid cartilage
● C. Cricoid cartilage
● D. Cricothyroid membrane
● E. None of the above
C. Cricoid cartilage
Choices of graft for anterior cervical fusion includes autologous graft (from iliac crest), nonautologous bone (cadaveric), bone substitutes (hydroxylapatite), or synthetic (PEEK, titanium) filled with osteogenic material. All of the following are benefits of anterior cervical plating except?
● A. It reduces pseudoarthrosis rate and graft problem
● B. It helps to maintain lordosis
● C. It is recommended for improvement of clinical outcome
● D. It is recommended to improve arm pain
C. It is recommended for improvement of clinical outcome
Postoperative check following ACDF includes which of the following?
● A. Checking for evidence of airway obstruction (check for hematoma, respiratory distress, extreme difficulty in swallowing, tracheal deviation)
● B. Weakness of nerve root of the level operated
● C. Long tract signs (Babinski) which may indicate cord compression by spinal epidural hematoma
● D. Hoarseness of voice which may show RLN injury
● E. All of the above
E. All of the above
ACDF complications include the following except?
● A. Exposure injuries (perforation of viscus like pharynx or esophagus or trachea, vocal cord paresis with incidence of 4% permanent and 11% temporary, vertebral artery injury with 0.3% incidence, carotid injury, CSF fistula, Horner syndrome, thoracic duct injury, thrombosis of internal jugular vein)
● B. Spinal cord or nerve root injury
● C. Bone fusion problems like failure of fusion (pseudoarthrosis), anterior kyphotic angulation, graft extrusion
● D. Wound infection, postoperative pneumothorax or hemothorax
● E. All of the above
E. All of the above
Indications for posterior keyhole laminotomy include which of the following?
● A. Monoradiculopathy with posterolateral soft disk sequestration
● B. Radiculopathy in patients who are professional singers or speakers
● C. For lower or upper cervical nerve root compression where anterior approach is more difficult
● D. In patients with herniated disk where it is desired to avoid fusion
● E. All of the above
E. All of the above
Posterior cervical decompression is usually reserved for which of the following cases?
● A. Multiple cervical disks or osteophytes (ACD is usually used to treat only two or three levels without myelopathy)
● B. Where cervical stenosis is more diffuse and more significant as compared to anterior pathology
● C. In professional speakers or singers
● D. All of the above
D. All of the above
A patient presented with weakness of forearm flexion, paresthesias in upper arm and thumb, and diminished biceps reflex. What is the level of herniated cervical disk?
● A. C2–C3
● B. C3–C4
● C. C4–C5
● D. C5–C6
● E. C6–C7
D. C5–C6
Which physical examination test for cervical disk herniation is analogous to straight leg raising test for lumbar disk herniation?
● A. Spurling test
● B. Axial manual spinal traction
● C. Shoulder abduction test
● D. FABER test
● E. Patrick test
A. Spurling test
What is the accuracy of CT myelogram for cervical disk disease?
● A. 70%
● B. 75%
● C. 80%
● D. 90%
● E. 98%
E. 98%
Which of the following is the most frequent radiculopathy mimicking carpal tunnel syndrome?
● A. C2
● B. C4
● C. C5
● D. C6
● E. C7
D. C6
How many patients with acute cervical radiculopathy due to cervical disk herniation can improve without surgery?
● A. 70%
● B. 80%
● C. 85%
● D. 90%
● E. 98
D. 90%
A patient underwent ACDF and developed Horner syndrome. Sympathetic plexus lies within which of the following?
● A. Cricothyroid
● B. Longus coli
● C. Sternocleidomastoid
● D. Omohyoid
● E. Belly of digastric
B. Longus coli
The addition of an anterior plate to an ACDF is recommended for what purpose?
● A. Reduce the pseudarthrosis rate
● B. Reduce graft problems
● C. To maintain lordosis
● D. Improve clinical outcome
● E. To improve arm pain
D. Improve clinical outcome
A patient developed difficulty in swallowing after ACDF. Laryngoscopy for postoperative dysphagia in this case is indicated if symptoms persist for how long?
● A. 24 hours
● B. 3 days
● C. 5 days
● D. > 2 weeks
● E. > 1 month
D. > 2 weeks
What is the most common muscle flap for repair of esophageal perforation?
● A. Sternocleidomastoid
● B. Radial forearm
● C. Pectoralis
● D. Infrahyoid
● E. Omohyoid
A. Sternocleidomastoid
Cervical spinal spondylosis usually implies a more widespread age-related degenerative condition of the cervical spine including various combinations of which of the following?
● A. Congenital cervical spinal stenosis (the shallow cervical canal) and degeneration of the intervertebral disk producing a focal stenosis due to a cervical bar which can be due to an osteophytic spur or protrusion of intervertebral disk material
● B. Hypertrophy of lamina, dura, articular facets, and ligaments (ligamentum flavum, PLL, OPLL, ossification of ligamentum flavum) plus subluxation due to disk and facet joint degeneration
● C. Altered mobility and telescoping of the spine due to loss of height of VBs and disks, which is also called as shingling of laminae
● D. Alteration of normal lordosis curvature including excessive lordosis or kyphosis
● E. All of the above
E. All of the above
In case of myelopathy, the histological findings are degeneration of the central gray matter at the level of compression, degeneration of the posterior column above the lesion, and demyelination of the lateral columns especially corticospinal tracts (anterior spinal tracts are relatively spared). Following are included in the pathogenesis of cervical myelopathy except?
● A. Direct cord compression between osteophytic bars and hypertrophy or infolding of the ligamentum flavum especially if superimposed on congenital narrowing or cervical subluxations
● B. Ischemia due to compression of the vascular structures
● C. Repeated local cord trauma by normal movements in the presence of protruded disks and/or osteophytic bars
● D. Compression due to hypertrophy of the anterior longitudinal ligament
D. Compression due to hypertrophy of the anterior longitudinal ligament
Cervical spondylosis is the most common cause of myelopathy in patients more than 55 years of age, and cervical spondylotic myelopathy (CSM) is rare in patients less than 40 years of age. CSM develops in almost all patients with more than or equal to 30% narrowing of cross-sectional area of the cervical
spinal canal. Clinical problems that can occur with cervical spondylosis include myeloradiculopathy which includes radiculopathy and myelopathy and the second one is pain and paresthesias in the head, neck, and shoulders with little or no suggestion of radiculopathy nor abnormal physical findings. Which of the following statements regarding individual symptoms of CSM is correct?
● A. The earliest motor findings are typically weakness in the triceps and hand intrinsics with wasting of the hand muscles and slow stiff opening and closing of the fist. Clumsiness with fine motor skills (writing, buttoning buttons) is common. There is often proximal weakness of lower extremities
(mild to moderate iliopsoas weakness in 54%) and spasticity of the lower extremities
● B. Sensory disturbance may be minimal and when it occurs it is like glove distribution sensory loss in the hands. A sensory level may occur a number of levels below the area of cord compression. Lower extremity often exhibits loss of vibratory sense (in 82% cases) and occasionally has reduced pin prick
sensations (9%)
● C. In 72 to 87% of cases, reflexes are hyperactive at a varying distance below the level of stenosis and clonus, Babinski, or Hoffmann’s sign may be present. Dynamic Hoffmann’s sign may be more sensitive while inverted radial reflex is said to be pathognomonic of CSM
● D. Urinary urgency and frequency are common in CSM, while urinary incontinence is rare. Anal sphincter disturbances are uncommon
● E. All of the above
E. All of the above
Which of the following are included in the cervical spondylotic myelopathic syndromes?
● A. Transverse lesion syndrome: Most frequent syndrome, possibly an end stage of the disease process
● B. Motor system syndrome: Mixture of lower motor neuron findings in the upper extremity and upper motor neuron finding in the lower extremities which can mimic ALS
● C. Central cord syndrome: Motor and sensory involvement producing greater deficit in the upper extremities than the lower extremities results in the so-called numb-clumsy hand syndrome. Lhermitte’s sign may be more common in this group
● D. Brown-Sequard syndrome: Upper motor neuron weakness ipsilateral to the side of greater narrowing while contralateral impairment of pain, temperature, and joint position sense
● E. Brachialgia and cord syndrome: Primarily radiculopathy
with lesser association with long tract involvement
● F. All of the above
F. All of the above
According to the modified Japanese Orthopedic Association Scale, severe spondylotic myelopathy implies Benzel mJOA grade of how much?
● A. More than or equal to 15
● B. 12 to 14
● C. Less than or equal to 11
● D. More than 9
● E. None of the above
C. Less than or equal to 11
Amyotrophic lateral sclerosis (ALS) is anterior horn motor neuron disease which can mimic motor system syndrome of cervical spondylotic myelopathy (CSM). Triad of ALS are atrophic weakness of hands and forearms, mild lower extremity spasticity, and diffuse hyperreflexia. Which of the following features can help differentiate ALS from CSM?
● A. In ALS sensory symptoms are conspicuously absent while in CSM hand numbness may occur
● B. Bulbar symptoms like dysarthria and hyperactive jaw jerk may occur in ALS but are absent in CSM
● C. ALS causes extensive weakness/muscle atrophy of hands usually with fasciculations
● D. ALS will cause LMN findings in the tongue like visible fasciculations and positive sharp waves on EMG or in the lower extremity like atrophy and fasciculations
● E. CSM or herniated cervical disk usually includes neck and shoulder pain, limitation of neck movements, sensory changes, and LMN findings restricted to one or two spinal cord segments
● F. All of the above
F. All of the above
Cervical canal stenosis is spina canal narrowing sufficient to produce spinal cord compression and thereby spinal cord symptoms. Cervical spondylotic myelopathy (CSM) is rare in patients with canal diameter more than 16 mm, and its risk is increased in patients with less than 14-mm diameter. Values
less than or equal to 10 mm are likely to be associated with myelopathy while in average patients with CSM, canal diameter is around 11.8 mm. Which of the following findings are found in CSM patients with poor outcome?
● A. Multilevel hyperintensity within the spinal cord parenchyma in T2WI
● B. Single-level T2WI hyperintensity with corresponding T1WI hypointensity
● C. Spinal cord atrophy (transverse area less than 45 mm2)
● D. Banana-shaped cord in axial images
● E. Snake eyes within the spinal cord on axial T2WI may be related to cystic necrosis of cord and is correlated with pooroutcome
● F. All of the above
F. All of the above
Nonoperative management of cervical spondylotic myelopathy includes which of the following?
● A. Prolonged immobilization with rigid cervical bracing
● B. Modified activities to eliminate high-risk activities
● C. Bed rest
● D. Anti-inflammatory medications
● E. All of the above
E. All of the above
Patients with mJOA score of more than 12 may derive significant improvement from surgery and deterioration from this point may be ominous. For degenerative cervical radiculopathy, patients do better with anterior decompression with/without fusion and cause rapid relief of pain in arm and neck
and of sensory loss within 3 to 4 months while relief of symptoms like weakness of wrist extension, elbow extension, shoulder abduction, and internal rotation may take up to how long?
● A. 9 months
● B. 6 months
● C. 3 months
● D. More than or equal to 12 months
● E. More than 18 months
D. More than or equal to 12 months
Situations where posterior approach would generally be the initial choice include which of the following?
● A. Congenital cervical stenosis
● B. Disease over more than or equal to three levels
● C. Cases of OPLL
● D. Primary posterior pathology like infolding of ligamentum flavum
● E. All of the above
E. All of the above
Hard calcified disks are commonly found in thoracic spine. Which of the following is sometimes called a hard disk in cervical spine?
● A. Shallow canal
● B. Osteophyte
● C. Lamina
● D. Hypertrophied ligamentum flavum
● E. Facet joint capsule
B. Osteophyte
The bow stringing of cervical spinal cord refers to which of the following?
● A. Kyphosis
● B. Lordosis
● C. Ossified posterior longitudinal ligament
● D. Hypertrophied ligamentum flavum
● E. Multilevel disk protrusion
A. Kyphosis
What is the earliest motor finding in cervical spondylotic myelopathy (CSM)?
● A. Weakness of triceps and hand intrinsics
● B. Proximal weakness of lower extremities
● C. Spasticity of lower limb
● D. Weakness of biceps
● E. Weak extension of elbow
A. Weakness of triceps and hand intrinsics
During degenerative cervical spine disease, which of the following is usually spared?
● A. Gray matter
● B. Posterior columns
● C. Lateral columns
● D. Corticospinal tracts
● E. Anterior spinal tracts
E. Anterior spinal tracts
What is the pathognomonic test for cervical spondylosis myelopathy?
● A. Lhermitte’s sign
● B. Hoffmann’s sign
● C. Dynamic Hoffmann sign
● D. Inverted radial reflex
● E. Babinski’s reflex
D. Inverted radial reflex
Amyotrophic lateral sclerosis may be difficult to differentiate from cervical spondylosis myelopathy and patients with the former are wrongly operated on for the suspicion of the latter. What is a typical feature of ALS that can differentiate it from cervical spondylotic myelopathy (CSM)?
● A. Absence of sensory findings
● B. Absence of bulbar symptoms
● C. Absence of tongue fasciculations
● D. Absence of widespread motor weakness with fasciculations
● E. MR
A. Absence of sensory findings
What is the ratio of the AP diameter of the spinal canal at the mid vertebral body level to the vertebral body at the same location?
● A. Pavlov’s
● B. Lhermitte’s
● C. Steele’s
● D. Babinski’s
● E. Spence’s
A. Pavlov’s
What is the cervical spine canal diameter above which a patient rarely develops myelopathy?
● A. 4 mm
● B. 8 mm
● C. 10 mm
● D. 12 mm
● E. 16 mm
E. 16 mm
The transverse area of the spinal cord is reduced at the level of maximum compression in cervical spondylosis myelopathy and on axial images what does the cord look like?
● A. Double lumen
● B. Tram track
● C. Owl’s eye
● D. Bamboo
● E. Banana
E. Banana
For cervical spondylotic myelopathy (CSM), a posterior approach is favored if the disease spans over how many levels?
● A. > 1 level
● B. > 2 levels
● C. > 3 levels
● D. > 4 levels
● E. > 5 levels
C. > 3 levels
For posterior approach decompression of cervical spine, a standard laminectomy refers to laminectomy at what level?
● A. C1
● B. C2
● C. C3–C6
● D. C2–C7
● E. C1–T1
C. C3–C6
A motor decline of deltoid muscle strength by ≥ 1 grade within 6 weeks of cervical spine surgery is which postoperative palsy?
● A. C3 palsy
● B. C4 palsy
● C. C5 palsy
● D. C6 palsy
● E. C7 palsy
C. C5 palsy
Scoliosis is defined as lateral curvature of the spine in the coronal (frontal) plane with Cobb angle more than what?
● A. 8 degrees
● B. 10 degree
● C. 12 degrees
● D. 14 degrees
● E. 16 degrees
B. 10 degree
Cobb angle can be measured between two lines, first drawn tangential to the superior endplate of superior vertebra and the second is drawn tangential to the inferior endplate of inferior vertebra. How can this angle be obtained?
● A. Sagittal X-ray
● B. Coronal X-ray
● C. Sagittal CT scan
● D. Coronal MRI films
● E. None of the above
B. Coronal X-ray
The absolute value of lumbar spinal lordosis should be about 30 degrees greater than the absolute value of the thoracic kyphosis (e.g., a patient with thoracic kyphosis of 20 degrees should have a lumbar lordosis of approximately–50 degrees). What should be range of lumbar lordosis in normal individuals?
● A. 10 to 30 degrees
● B. 10 to 40 degrees
● C. 20 to 40 degrees
● D. 20 to 50 degrees
● E. 20 to 60 degrees
B. 10 to 40 degrees
Sagittal vertical axis is a horizontal distance from the posterior edge of the S1 endplate to a plumb line dropped from the mid C7 vertebral body. What is its normal value?
● A. < 3 cm
● B. < 7 cm
● C. < 5 cm
● D. < 9 cm
● E. < 1 cm
C. < 5 cm
Pelvic tilt is the angle between the vertical reference line and a line drawn from the midpoint of the femoral head to the midpoint of the S1 endplate. What should be the normal value
of this angle?
● A. 5 to 15 degrees
● B. 10 to 20 degrees
● C. 10 to 25 degrees
● D. 15 to 30 degrees
● E. 20 to 30 degrees
C. 10 to 25 degrees
Pelvic incidence is the angle between a point perpendicular to the S1 endplate and a line drawn from the midpoint of the femoral head to the midpoint of the S1 endplate. What is its normal value approximately?
● A. 35 degrees
● B. 45 degrees
● C. 50 degrees
● D. 55 degrees
● E. 60 degrees
C. 50 degrees
Sacral slope is the angle between the horizontal reference line and the S1 endplate and it normal value is 36 to 42 degrees. Which of the following statements is correct?
● A. SS = PI− PT
● B. SS = PT− PI
● C. SS = PI + PT
● D. SS = PT multiplied by PI
● E. None of the above
A. SS = PI− PT
Lumbar lordosis is the angle between the top of S1 and the top of L1 vertebra. What is its normal value?
● A. 10 to 30 degrees
● B. 20 to 40 degrees
● C. 20 to 50 degrees
● D. 10 to 40 degrees
B. 20 to 40 degrees
Thoracic kyphosis is the angle between top of T4 and the bottom of the T12 vertebrae. What is its normal value?
● A. 41 ± 12 degrees
● B. 39 ± 12 degrees
● C. 37 ± 12 degrees
● D. 43 ± 12 degrees
A. 41 ± 12 degrees
The spine is generally kyphotic between T1 and T12 while between L1 and L5 it is what?
● A. Scoliotic
● B. Lordotic
● C. Kyphotic
● D. Hyperacusis
● E. None of the above
B. Lordotic
Scoliosis is defined as lateral curvature of the spine in the coronal plane with what Cobb angle?
● A. > 10 degrees
● B. > 15 degrees
● C. > 20 degrees
● D. > 25 degrees
● E. > 30 degrees
A. > 10 degrees
The vertebra whose center is most laterally displaced from the central line is called what?
● A. Center
● B. Apex
● C. Master
● D. Dextro
● E. Levo
B. Apex
As compared to thoracic spine, the lumbar spine should have lordosis more than what?
● A. 5 degrees
● B. 10 degrees
● C. 15 degrees
● D. 20 degree
● E. 30 degrees
E. 30 degrees
Pelvic tilt is the angle between the vertical reference line (VRL) and a line drawn from the midpoint of the femoral head to the midpoint of the S1 endplate. Normally, it should be less than what?
● A. 20 degrees
● B. 30 degrees
● C. 40 degrees
● D. 90 degrees
● E. 180 degrees
A. 20 degrees
Patients with higher sacral slope have a higher chance of developing which of the following?
● A. Spinal stenosis
● B. Spondylolisthesis
● C. Scoliosis
● D. Kyphosis
● E. Lordosis
B. Spondylolisthesis
Lumbar lordosis (LL) is the angle between the top of S1 and the top of L1. For pelvic harmony, LL should be within how many degrees of pelvic incidence (PI)?
● A. 9
● B. 11
● C. 13
● D. 15
● E. 20
A. 9
According to Roussouly classification of lumbar lordosis if the SS = 35–45 degrees, apex of LL is at the center of L4 VB. What is the implication of this type?
● A. LL is distributed over only approximately 3 lumbar levels
● B. Entire spine is hypolordotic and hypokyphotic
● C. Well-balanced spine
● D. LL is distributed over > 5 levels
● E. PI is usually high
C. Well-balanced spine
Scoliosis is defined as lateral curvature of the spine in the coronal plane (frontal plane) with Cobb angle greater than 10 degrees. Which of the following is the type of idiopathic scoliosis which occurs at the age of 10 to 17 years and with overwhelming female predominance?
● A. Congenital scoliosis
● B. Infantile scoliosis
● C. Juvenile scoliosis
● D. Adolescent idiopathic scoliosis
● E. None of the above
D. Adolescent idiopathic scoliosis
Patients with idiopathic scoliosis are more commonly females and mostly have dextroscoliosis (convex to right side). Imaging for these patients consist of lateral and neutral PA coronal X-rays and left-bending plus right-bending coronal X-rays are done only if surgery is planned. Which of the following statements is incorrect regarding treatment of these patients?
● A. Treatment is based on skeletal maturity and magnitude of scoliosis
● B. Growing patients with curves less than 25 degrees or skeletally mature patients with curves less than 45 to 50 degrees are managed with observation only
● C. Bracing prevents progression but does not correct scoliosis and bracing makes no sense in skeletally mature patients
● D. Use of bracing in patients with curves 25 to 40 degrees who are still growing or in skeletally immature patients with curves more than 45 degrees is done to tide them over until they can have surgery
● E. For growing patients with early scoliosis, there is no need of fixation or vertebral body tethering
E. For growing patients with early scoliosis, there is no need of fixation or vertebral body tethering
“Reduced growth in areas of compressed cartilage (physes) in the curve concavity may result in progression of scoliosis through development of vertebral body wedging from asymmetric growth”; this principle for adult idiopathic scoliosis is known as what?
● A. Heuber principle
● B. Hueter-Volkmann principle
● C. Heishemer-Volkmann principle
● D. Spence principle
● E. None of the above
B. Hueter-Volkmann principle
Which of the following physical findings can be found in scoliotic patients?
● A. Shoulder asymmetry, pelvic tilt, age length discrepancy, breast asymmetry, and trunk shift (shift of thorax to one side as compared to the pelvis)
● B. Adams forward bend test which is done by putting the feet of the patient together and forward bending with the knees straight and arms dangling which will result in a rib hump on the convex side of thoracic scoliotic curve
● C. Neurologic examination to look for abdominal cutaneous reflex, deep tendon reflexes, strength, and sensations
● D. Evidence of underlying conditions like arachnodactyly, skin pigment changes, tufts of hair, or dimpling over the spine
● E. All of the above
E. All of the above
Riser staging for assessing skeletal maturity in adolescent patient to guide decisions for bracing and timing of surgery includes following except?
● A. Stage 0 is no ossification center in the iliac crest apophysis
● B. Stages 1, 2, and 3 consist of apophysis of iliac crest up to less than 25%, 25 to 50%, and 50 to 75%, respectively
● C. Stage 4 consists of more than 75% of apophysis of the iliac crest, while stage 5 consists of complete ossification and fusion of the iliac crest apophysis
● D. Grades 0 and 1 are growing rapidly, and scoliosis curve acceleration begins in stage 0
● E. Grades 4 and 5 are growing rapidly
E. Grades 4 and 5 are growing rapidly
Which of the following are strong indications of MRI in scoliotic patients?
● A. Early-onset scoliosis in age less than 10 years
● B. Adolescent idiopathic scoliosis in males
● C. Atypical curves like thoracic levoscoliosis, kyphosis
● D. Hyperkyphosis
● E. Neurologic deficit
● F. All of the above
F. All of the above
Major curve in a scoliotic patient is the largest curve and there can be only one major curve which is almost always present at MT (main thoracic from T6 to T11, T12 disk) or TL/L (thoracolumbar/lumbar). There are other two minor curves besides the major curve, which can be structural or nonstructural. Which of the following is a structural criterion of minor curve?
● A. Side-bending residual Cobb angle more than or equal to 25 degrees
● B. A and/or T2–T5 kyphosis more than or equal to plus 20 degrees
● C. A and/or T10–L2 kyphosis more than or equal to plus 20 degrees
● D. All of the above
D. All of the above
Lenke classification is the de facto standard for classifying AIS. Following are true regarding this classification except?
● A. Type one is main thoracic
● B. Type two is double thoracic
● C. Type three is double major
● D. Type four is triple major
● E. Type five is thoracolumbar/lumbar
● F. Type six is thoracolumbar/lumbar minor thoracic
F. Type six is thoracolumbar/lumbar minor thoracic
Two basic types of braces are TLSO with a goal to wear for 18 to 23 h/d and night time TLSO with a goal to wear for 10 hours per night. Which of the following are contraindications of bracings?
● A. In skeletally mature patients
● B. Thoracic lordosis
● C. Insensate patients or insufficient neuromuscular function
● D. ± significant obesity
● E. Sanders scale 2 to 5 with curves more than or equal to 30 degrees
● F. All of the above
F. All of the above
Which of the following are the surgical fusion goals for a scoliotic patient?
● A. Correct scoliosis as much as possible
● B. Restore thoracic kyphosis
● C. Fuse all structural curves
● D. All of the above
D. All of the above
Which of the following is usually correct for adolescent idiopathic scoliosis (AIS)?
● A. Presents at 4 to 9 years of age
● B. Overwhelming male dominance
● C. Almost all with dextroscoliosis
● D. Majority are lumbar
● E. Potentially curable with Mehta serial casting
C. Almost all with dextroscoliosis
Risser system grades ossification and fusion of the iliac crest apophyses. Ossification of 25 to 50% of the iliac crest apophysis is graded as what stage?
● A. 1
● B. 2
● C. 3
● D. 4
● E. 5
B. 2
In treatment of AIS, observation is appropriate for which curves?
● A. < 25 degrees
● B. > 25 degrees
● C. < 20 degrees
● D. > 20 degrees
● E. < 30 degrees
A. < 25 degrees
Bracing is indicated in AIS for which patients?
● A. Skeletally mature
● B. Insensate patients
● C. Sander stage 1
● D. Sanders stage 3
● E. Thoracic lordosis
C. Sander stage 1
How is AdIS different from AIS?
● A. AIS presents with back and LE pain
● B. Coronal and sagittal malalignments are more common in AdIS
● C. Curves are more flexible in AdIS
● D. Sacrum needs to be included in surgical fusion in AIS
● E. In AIS, a degenerative lumbosacral fractional curve is often present as a result of degeneration
B. Coronal and sagittal malalignments are more common in AdIS
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
Anterior subluxation of one vertebral body (VB) on another is spondylolisthesis. It occurs most commonly at which level?
● A. L1–L2
● B. L2–L3
● C. L3–L4
● D. L4–L5
● E. L5–S1
E. L5–S1
Commonly a true disk herniation occurs with relation to spondylolisthesis at which level?
● A. At the same level
● B. One level below
● C. One level above
● D. Two levels above
● E. Two levels below
C. One level above
According to the Meyerding grade, spondyloptosis is listhesis of what percent?
● A. > 25%
● B. 25 to 50%
● C. 50 to 75%
● D. 75 to 100%
● E. > 100%
E. > 100%
On spine CT, what is the lateral recess height diagnostic of lateral recess syndrome?
● A. 7 mm
● B. 5 mm
● C. 4 mm
● D. 3 mm
● E. 1 mm
E. 1 mm
In isthmic spondylolisthesis, lesions without sclerosis that show increased uptake on bone scan and MRI high signal changes on STIR may be treated with which of the following?
● A. Boston brace
● B. Steroid
● C. Injection therapy
● D. Crutches
● E. Orthopedic mattress
A. Boston brace
Which of the following is primarily an extension limiting procedure for lumbar spine that can be used as a stand-alone procedure?
● A. Laminectomy
● B. Anterior lumbar interbody fusion
● C. Transforaminal lumbar interbody fusion
● D. Oblique lumbar interbody fusion
● E. Interspinous spacer
E. Interspinous spacer
A patient presents with backache radiating to lower limbs which increases during walking. This patient has obvious spinal deformity with scoliosis, forward flexion at the wrist, and walking with knees bent. This patient is more than 60 years of age. Standing coronal view X-ray was done which showed Cobb
angle of more than 10 degrees. What is the most probable diagnosis in this case?
● A. Adult degenerative spine disease
● B. Adolescent idiopathic scoliosis
● C. Adult idiopathic scoliosis
● D. Adult spinal deformity
● E. None of the above
A. Adult degenerative spine disease
SRS-Schwab classification of adult degenerative spinal deformity has which of the following parameters?
● A. Coronal curve types
● B. Sagittal modifiers
● C. Global alignment
● D. Pelvic tilt
● E. All of the above
E. All of the above
Treatment options for adult degenerative scoliosis are based on clinical symptoms and include the following except?
● A. Observation only
● B. Focal decompression
● C. Surgical correction of deformity and stability using traditional open surgery (decompression by laminectomy, PLIF, TLIF, pedicle screw/rod fixation), minimal invasive spine surgery, and combined (both open and MIS)
● D. Anterior corpectomy and cage fixation
● E. None of the above
D. Anterior corpectomy and cage fixation
Summary for spinopelvic alignment objectives include the following except?
● A. LL = PI ± 9 degrees
● B. PT less than 20 degrees
● C. PSVL and SSV should be less than 30 degrees
● D. SVA less than 5 cm
C. PSVL and SSV should be less than 30 degrees
Which of the following is Schwab grade 3 of surgical spine osteotomies?
● A. Resection of the inferior facet and joint capsule
● B. Resection of the superior and inferior facets, ligamentum flavum, and possible lamina and spinous process
● C. Partial wedge resection of the vertebral body and the posterior elements with the pedicles
● D. Partial wedge resection of the vertebral body and the posterior elements with the pedicles plus inclusion of at least a portion of the endplate and one adjacent disk
● E. Complete removal of the vertebra and both adjacent disks
C. Partial wedge resection of the vertebral body and the posterior elements with the pedicles
How much lumbar lordosis can be obtained by Schwab grade 1 osteotomy plus ACR?
● A. 1 degree
● B. 6 degrees
● C. 5 to 10 degrees
● D. 16 degrees
● E. 30 to 40 degrees
D. 16 degrees
Morbid obesity (BMI more than 40) doubles the risk of complications of all types including cardiac, renal, pulmonary, and wound complications with spine surgery, and mortality is increased by how much?
● A. Doubled
● B. Tripled
● C. Four times increased
● D. Five times increased
● E. None of the above
B. Tripled
Pedicle subtraction can increase LL by 30 to 40 degrees. What is the Schwab grade?
● A. Grade 1
● B. Grade 2
● C. Grade 3
● D. Grade 4
● E. Grade 5
C. Grade 3
Coronal balance is measured on AP standing scoliosis X-ray. A plumb line is drawn straight down from the center of the C7 vertebral body. There is coronal imbalance if this falls from midline of the sacrum by more than what?
● A. 2 cm
● B. 3 cm
● C. 4 cm
● D. 5 cm
● E. 6 cm
C. 4 cm
CT scan in case of adult degenerative scoliotic patient can provide which of the following information?
● A. Any fusions (spontaneous or surgical)
● B. Vacuum disk (which imply hypermobility)
● C. Calcifications (in herniated disks, ligamentum flavum)
● D. For obtaining measurements for surgical instrumentation
● E. All of the above
E. All of the above
Before surgery for adult spinal deformity (ASD), surgeons use teriparatide for how long to rapidly increase the strength of osteoporotic bone?
● A. 2 weeks
● B. 4 weeks
● C. 6 weeks
● D. 3 months
● E. 6 months
D. 3 months
Standing scoliosis X-ray must image from C7 down to what level?
● A. T7
● B. Midthoracic level
● C. Thoracolumbar junction
● D. L1
● E. Femoral heads
E. Femoral heads
The degree of curve rigidity after scoliosis surgery can be determined with which of the following?
● A. Dynamic standing scoliosis X-ray
● B. Flexion–extension X-rays
● C. CT scan
● D. CT myelogram
● E. MRI with contrast
A. Dynamic standing scoliosis X-ray
Pre- and postoperative standing scoliosis X-rays help to confirm that alignment objectives are achieved. Following views are required for adolescent idiopathic scoliosis (AIS) except?
● A. Standing coronal
● B. Lateral
● C. Left bending
● D. Right bending
● E. Sagittal
E. Sagittal
According to Schwab’s classification of surgical osteotomies, a complete removal of the vertebra and both adjacent disks and rib resections extended over multiple vertebral levels is what grade?
● A. Zero
● B. II
● C. III
● D. V
● E. VI
E. VI
Anterior lumbar interbody fusion (ALIF) is best for lumbar level where the great vessels tend not to interfere with the access, and where every degree of correction produces a more significant amount of improvement in vertical alignment. Which level is this?
● A. L1–L2
● B. L2–L3
● C. L3–L4
● D. L4–L5
● E. L5–S1
E. L5–S1
Standing scoliosis X-rays provide information about scoliosis and which of the following?
● A. Sagittal balance
● B. Cobb’s angle
● C. Anterolisthesis
● D. Retrolisthesis
● F. Dynamic stability
A. Sagittal balance
A patient presents with pain in the back, joint pain, and multiple nerve root compressive symptoms (due to expansion of woven bone, osteoid tissue). Lab work shows elevated alkaline phosphatase and urinary hydroxyproline. CT of spine shows hypertrophic changes at the facet joints and X-rays show cortical thickening, sclerotic changes, and osteolytic areas. Which of the following is correct regarding Paget’s disease?
● A. It is a disorder of osteoclasts causing increased rate of bone resorption
● B. Reactive osteoblastic activity with overproduction of new, weaker, woven bone
● C. Initial hot phase
● D. Cold phase in the last
● E. All of the above
E. All of the above
A patient presents to neurosurgical OPD with complaints of nonradiating low back pain, morning back stiffness, hip pain with swelling, which is exacerbated by inactivity and improved with exercise. X-ray of this patient shows bridging of syndesmophytes between vertebral bodies creating the so-called bamboo spine appearance and sacroiliitis as well. RA factor in serum of this patient is negative. This patient is diagnosed using Modified New York criteria. What is the diagnosis in this case?
● A. Rheumatoid arthritis
● B. Reiter’s syndrome
● C. Forestier’s disease
● D. Ankylosing spondylitis
● E. Metastatic prostate cancer
D. Ankylosing spondylitis
The most common surgical intervention in ankylosing spondylitis is orthopedic total hip arthroplasty, while the most frequent fracture site in ankylosing spondylitis is which of the following?
● A. Lumbar spine
● B. Thoracolumbar spine
● C. Cervical spine
● D. Thoracic spine
● E. Lumbar sacral junction
C. Cervical spine
A 55-year-old male patient presents to OPD with signs of myelopathy and positive Hoffmann’s sign. His MRI shows a hypointense signal from C3 to C6 level on T2WI which is obliterating CSF signal with cord compression anteriorly. His CT of cervical spine shows calcified anterior longitudinal ligament behind c4, c5, and c6 vertebral bodies. What is the most common location of OPLL in spine (which is 70 to 75%)?
● A. Cervical
● B. Thoracic
● C. Lumbar
● D. Both cervical and thoracic
● E. None of the above
A. Cervical
Which of the following is included in the pathological classification of ossified posterior longitudinal ligament?
● A. Segmental (39%), confined to the space behind the vertebral bodies
● B. Continuous (17%), extending from vertebral body to vertebral body spanning the disk space
● C. Mixed (25%), combined elements of both A and B
● D. Other variants (5%), a rare type of OPLL that is contiguous with the end plates and is confined to the disk space
● E. All of the above
E. All of the above
Which of the following statements is correct regarding Nurick grade of disability from cervical spondylosis?
● A. Grade 0: signs or symptoms of root involvement without myelopathy
● B. Grade 1: myelopathy but no difficulty in walking
● C. Grade 2: slight difficulty in walking, able to work
● D. Grade 3: difficulty in walking but not needing assistance, unable to work full time
● E. Grade 4: able to walk only with assistance or walker
● F. Grade 5: chair bound or bed ridden
● G. All of the above
G. All of the above
A patient presents to neurosurgical OPD with complaints of backache and anterior wedging of at least 5 degrees of more than or equal to three adjacent thoracic vertebral bodies. Associated findings in Scheuermann’s kyphosis include the following except?
● A. End plate irregularities
● B. Posterior narrowing of disk space
● C. Schmorl’s nodes
● D. Scoliosis
● E. Spondylolysis in 50%
B. Posterior narrowing of disk space
Rheumatoid arthritis (RA) most commonly involves cervical spine (in 44–88% cases of RA) which can be atlantoaxial subluxation, basilar impression, or subaxial subluxation. Which of the following is included in the Ranawat classification of myelopathy in RA?
● A. Class 1: no neural deficit
● B. Class 2: subjective weakness + hyperreflexia + dysesthesia
● C. Class 3: objective weakness plus long tract signs
● D. Class 3A, ambulatory, and class 3 B, quadriparetic and nonambulatory
● E. All of the above
E. All of the above
Spinal cord infarction can be due to atherosclerosis of radicular arteries in elderly patients, clamping of aorta during surgery, trauma, hypotension, aortic dissection, or embolization of spinal arteries. Acute anterior spinal cord syndrome, which results in motor paralysis below the level of injury, loss of pain
and temperature with preserved vibratory and position sense, and loss of sphincter control, is because of involvement of which artery?
● A. Anterior spinal artery
● B. Posterior spinal artery
● C. Radicular arteries
● D. Abdominal aorta
● E. None of the above
A. Anterior spinal artery
Noncontrast CT scan is probably the most sensitive test for detecting pneumorrhachis as well as air in other body compartments. What are the surgical indications of pneumorrhachis (air in the spinal canal)?
● A. Intracranial hypo-/hypertension refractory to medical management
● B. Significant or persistent CSF leak
● C. Evidence of unidirectional ball valve (tension pneumorrhachis) near at-risk nervous tissue
● D. Herniation or serious injury of adjacent structures (for example, lungs) into the spinal cord
● E. All of the above
E. All of the above
Paget’s disease may be asymptomatic or present with pain, radiculopathy, and compression of cranial nerves as they pass through skull foramina. Which of the following is the most commonly affected cranial nerve?
● A. III
● B. VI
● C. VII
● D. VIII
● E. X
D. VIII
Paget’s disease depicts ivory bone. The treatment of the disease includes calcitonin derivatives that mainly act by which of the following mechanisms?
● A. Osteoclast activity reduction
● B. Osteoclast activity stimulation
● C. Osteoblast activity reduction
● D. Osteoblast activity stimulation
● E. Inhibition of intestinal calcium absorption
A. Osteoclast activity reduction
Ankylosing spondylitis gives rise to bamboo spine, Andersen lesions, and kyphosis. By definition, which joint is always affected?
● A. Scapulohumeral joint
● B. Sacroiliac joint
● C. Ankle joint
● D. Small joints at wrist
● E. Costovertebral
B. Sacroiliac joint
Which of the following is a test for monitoring ongoing physical therapy and is done by measuring distraction between skin marks on the back before and after forward flexion to detect reduced mobility of the spine due to fusion?
● A. Schober test
● B. Patrick test
● C. Lhermitte sign
● D. Hoover test
● E. Ankylosing test
A. Schober test
What is the most common level affected by ossified posterior longitudinal ligament?
● A. Cervical
● B. Midthoracic
● C. Thoracolumbar
● D. Lumbar
● E. Lumbosacral
A. Cervical
There are four patterns of ossified posterior longitudinal ligament. When it extends from vertebral body to vertebral body, spanning disk space, it is which pattern?
● A. Segmental
● B. Skipping
● C. Continuous
● D. Punctate
● E. Mixed
C. Continuous
Which is the best test for demonstrating and accurately diagnosing ossified posterior longitudinal ligament?
● A. X-ray
● B. CT with coronal reconstruction
● C. CT myelogram
● D. MRI with contrast
● E. Bone scan
C. CT myelogram
