1) Acute pain that presents in the lateral arm and shoulder is suggestive of:

(A) Cervical myelopathy

(B) Thoracic outlet syndrome
(C) Radial tunnel syndrome
(D) Cervical disk herniation
(E) Diabetic neuropathy

Explanation:

Acute radiculopathies of the upper extremity are suggestive of soft cervical disk
herniations. Three types of soft disk herniations have been described:

 Intraforaminal is the most common and is often evidenced by radicular

symptoms in a dermatomal distribution.
 Posterolateral herniation results in predominantly motor symptoms.

 Midline disk herniations may result in myelopathy.

2) The superior aspect of the iliac crest often bisects this midline spinal structure:
(A) L2/L3 disk space
(B) L3 vertebral body
(C) L3/L4 disk space
(D) L4/L5 disk space
(E) L5/S1 disk space

Explanation:

The L4/L5 intervertebral disk space is located by placing your fingers at the top of a
patient's iliac crests, while allowing your thumbs to meet at the midline of the spine
between the palpable L4 and L5 spinous processes.

3) A 32-year-old woman is diagnosed on magnetic resonance imaging with a

far-lateral disk herniation at the L3/L4 level causing radiating right lower
extremity discomfort across the anterior aspect of her knee with no motor or
reflex abnormalities. Which of the following nerve roots is most likely
affected:

(A) L1
(B) L2
(C) L3
(D) L4
(E) L5

Explanation:

A far-lateral or foraminal disk herniation often affects the exiting or more proximal nerve
root. The traversing or more distal nerve root is typically affected from a posterolateral
disk herniation. In this case, the patient has a far-lateral disk herniation at the L3/L4 level
resulting in L3 nerve root symptomatology.
4) Which orthopedic test, designed to apply tension to the spinal cord producing
pain, involves having the patient lie supine while the examiner flexes the
patient's head to his chest:
(A) Kernig sign
(B) Hoover test
(C) Milgram test
(D) Naffziger test
 (E) Gaenslen test

Explanation:

The Kernig test involves the patient lying supine while the examiner forcibly flexes the
head to the chest applying tension to the spinal cord. The test is positive if pain is elicited
and indicates meningeal irritation in conditions such as meningitis.

 The Hoover test can help identify a patient who is malingering. This test
involves having the patient lie supine with the examiner's hands placed under
both of the patient's heels. The patient is asked to lift the affected leg. If a true
effort is made, the examiner should feel downward pressure in the patient's
opposite foot as he attempts to lift the affected leg. If no downward pressure is
felt, the patient purposely may not be trying and might be malingering.
 The Milgram test may be used in conditions with suspected intrathecal
pathology. While lying supine, the patient is asked to perform bilateral straight
leg lifts. If the patient can sustain his feet 2 inches off the ground for more 30
seconds, intrathecal pathology is less likely.
 The Naffziger test is designed to increase intrathecal pressure and thus pain by
compressing the jugular veins.

 The Gaenslen test is used to determine sacroiliac joint pathology.

5) A 42-year-old man sustained a twisting injury to his low back 5 months ago.
Since the injury, he has persistent low back pain that radiates into his right thigh
and down to his posterior calf. The patient underwent a magnetic resonance
imaging of his lumbar spine revealing a small posterolateral lumbar disk
herniation at the L4L5 level. Over the past month, the patient states that his leg
pain has been getting progressively better and has almost disappeared over the
past week with the use of nonsteroidal anti-inflammatory medications and
occasional bed rest. The next step in the management of this patient should be:

(A) A lumbar computed tomography scan

(B) Repeat magnetic resonance image
(C) Surgical excision of the herniated disk
(D) Continued conservative management
(E) Epidural steroid injection

Explanation:

The patient has shown continued improvement of his symptoms including the leg pain
with conservative treatment. Epidural steroids would be indicated if this patient had
continued or worsening leg pain and/or low back pain.
 6) Slide 1
A 50-year-old woman with 3 months of low back pain recently discovers a hard,
painless lump in her breast. Due to the back discomfort, she undergoes plain
radiography and subsequently a computed tomography scan (below). The most
likely diagnosis is:
(A) Osteomyelitis
(B) Osteoid osteoma
(C) Fracture
(D) Herniated nucleus pulposis
(E) Metastatic disease

Explanation:

The computed tomography scan reveals a destructive lesion involving the vertebral body
extending into the pedicle in a patient with a suspected breast malignancy. This is a
metastatic lesion until proven otherwise. This patient needs a thorough evaluation of her
breast lesion, as well as her spine lesion, including biopsies. An osteoid osteoma is seen
in a younger population and is seen on a computed tomography scan as a sclerotic round
lesion.

7) Which test is most specific for diagnosing spinal column infection:

(A) White blood count
(B) Erythrocyte sedimentation rate
(C) Carbon-reactive protein
(D) Blood culture
(E) Biopsy

Explanation:

Vertebral biopsy, either via open or computed tomography-guided means, is most specific even though false-negative rates for
closed and open biopsies are 30% and 14%, respectively.
 A patient’s white blood count may be normal even in acute spinal infection.
 Although often elevated, erythrocyte sedimentation rate and carbon-reactive protein are nonspecific tests.

 Blood cultures are negative in more than 75% of patients.

8) Which recommendations for the pharmacologic treatment of spinal cord injuries

resulted from the NASCIS-II trials:
(A) Treat all patients with a spinal cord injury with methylprednisolone 30 mg/kg over 1 hr followed by a maintenance rate of 5.4
mg/kg/hr for 23 hours.
 (B) Treat only patients who present within the first 8 hours of a spinal cord injury with methylprednisolone 30 mg/kg over 1 hr
followed by a maintenance rate of 5.4 mg/kg/hr for 23 hours.
(C) Treat all patients with a spinal cord injury with decadron 10 mg/kg bolus followed by 1 mg/kg/hr for 23 hours.
(D) Treat only patients who present within the first 8 hours of a spinal cord injury with decadron 10 mg/kg bolus followed by 1
mg/kg/hr for 23 hours.
(E) Treat only patients who present with complete spinal cord injuries within the first 8 hours of a spinal cord injury with
methylprednisolone 30 mg/kg over 1 hr followed by a maintenance rate of 5.4 mg/kg/hr for 23 hours.

Explanation:

The NASCIS-II recommendations are to treat patients who present with an incomplete
spinal cord injury within 8 hours of the injury with methylprednisolone 30 mg/kg over 1
hour followed by a maintenance rate of 5.4 mg/kg/hr for 23 hours. Because it is difficult to
tell which patients have a complete or incomplete spinal cord injury in this time frame due
to spinal shock, it has generally been accepted to treat all patients with spinal cord
injuries with this treatment protocol as long as they present within the first 8 hours of the
injury.

9) A patient has a fracture dislocation of the cervical spine. Which of the following
nerve roots must be spared to preserve intact finger extension:
(A) C5
(B) C6
(C) C7
(D) C8
(E) T1

Explanation:

Finger extensors are innervated by the C7 cervical spine nerve root.

Motor innervations include:

 Shoulder abduction (deltoid) - - C5

 Elbow flexion - - C5
 Wrist extension - - C6, C7
 Wrist flexion - - C7
 Finger extension - - C7
 Finger flexion - - C8

 Finger abduction/adduction - - T1
10) Which of the following nerve roots supplies motor innervation to the flexor
digitorum superficialis (FDS):
(A) C5
(B) C6
(C) C7
(D) C8
(E) T1

Explanation:

The FDS flexes the proximal interphalangeal joint and is innervated by the C8 cervical
spine nerve root. The FDS is innervated peripherally by the median nerve.

The flexor digitorum profundus flexes the distal interphalangeal joint and is also
innervated by the C8 cervical spine nerve root. The middle and index fingers are supplied
by the median nerve, and the ring and little fingers are supplied by the ulnar nerve.

11) A patient with a fracture dislocation of the spine has a sensory level at the
umbilicus. Which of the following nerve root levels indicates this finding:
(A) T2
 (B) T4
(C) T7
(D) T10
(E) T12

Explanation:

The skin of the umbilicus is innervated by the T10 nerve root.br>

In addition to knowing the innervation of selected muscles and the deep tendon reflexes,
the clinician should also know the sensory levels to localize pathologic processes.
 T4 Nipple line
 T7 Xiphoid process
 T10 Umbilicus

 T12 Groin

12) Slide 1
A 35-year-old man has neck pain following a motor vehicle accident. His axial
computed tomography scan is shown (Slide). The most likely diagnosis is:
(A) C4 compression fracture
(B) Clay shovelers fracture
(C) Bilateral facet dislocation
 (D) Unilateral facet dislocation
(E) Pseudosubluxation of C4 on C5

Explanation:

The axial computed tomography scan of C4-C5 shows a unilateral facet dislocation.
Notice that the superior facet of C5 lies posterior to the inferior facet of C4. This
relationship should be the exact opposite. Also, notice that C4 is rotated on the body of
C5 and translated forward.

13) The distinguishing phenotypic feature that differentiates a schwannoma from a

neurofibroma is:
(A) The consistently hard and irregular surface of a schwannoma tumor
(B) The lack of a capsule around a neurofibroma tumor
(C) The presence of a dissection plane between the tissue and a schwannoma tumor
(D) Distinctly differing locations of occurrence along the spinal axis
(E) There is no phenotypic distinguishing characteristic that differentiates a schwannoma from
a neurofibroma.

Explanation:

Nerve sheath tumors account for 25% of intradural spinal cord tumors in adults and can
be further broken down into either schwannomas or neurofibromas. Schwannomas are
more common than neurofibromas, most commonly occurring in patients 30 to 50 years
of age, equally between the sexes. Most schwannomas arise in the dorsal nerve root.
Neurofibromas, however, have a predilection to the ventral root. Both tumors primarily are
intradural but as many as 10% to 15% can escape through the dura to form a dumbbell
shape and exist as both an intradural and extradural tumor. Histologically, fibrous tissue
and nerve fibers make up a neurofibroma. Grossly, neurofibromas appear as a fusiform
enlargement of the nerve, making a clear distinction between tumor and nerve
impossible. Macroscopically, schwannomas look like smooth globoid masses sitting on
the nerve fiber and a clear resection plane is apparent.

14) Initially, the most appropriate method to evaluate a patient with suspected
peripheral nerve injury involves:
(A) An imaging study, preferably magnetic resonance imaging (MRI), of the injured region
(B) Electromyography and nerve conduction velocity studies
(C) A doppler ultrasound to study blood flow to the injured area
(D) An MRI of the entire spine to evaluate possible spinal cord injury
(E) A detailed neurologic evaluation noting distal motor function

Explanation:

After a traumatic injury to peripheral nerves, early clinical examination is imperative. The
key is to test for motor function in the most distal aspect of the nerve and be able to
localize the site of injury. Imaging studies are far less sensitive than clinical examinations.
Electromyography and nerve conduction velocity studies are usually performed during the
follow-up examination to assess for residual, or recovery of, function.

15) Superior articulating facets in the lumbosacral spine differ from those in the
thoracic spine because facets in the lumbosacral spine:
(A) Face posteriorly
(B) Face dorsomedially
(C) Have a thicker facet joint capsule
(D) Face superolaterally
(E) Are fused and are not true joints

Explanation:
The paired superior articular facets are directed dorsomedially with their corresponding
inferior articular processes directed ventrolaterally. These diarthrodial articulations
possess thin, lax joint capsules capable of a limited gliding articulation between adjoining
vertebrae. They permit flexion, lateral bending and extension, but resist rotation due to
both size and facet orientation. The facets alone can bear up to 18% of the compressive
load

16) Which of the following regions of the spine is normally straight:

(A) T1 to T6
(B) T7 to T12
(C) T10 to L2
(D) L1 to L4
(E) T12 to S1

Explanation:

The normal range of thoracic kyphosis is 20° to 50°. The mean in normal adults is 35°.
The normal range of lumbar lordosis is 40° to 80°. The mean in normal adults is
approximately 60°.

The spine is usually straight in the sagittal plane between T10 and L2. The majority of
lumbar lordosis occurs between L4 and S1.

17) Which of the following descriptions applies to the sacroiliac joint:

(A) The sacroiliac joint accounts for 15% of lower back pain.
(B) Pain is referred most commonly to the groin.
(C) Focal pain over the sacral sulcus is rare.
(D) Focal neurological deficits are common.
(E) Provocative tests (Patrick and Gaenslens) are useful predictors of joint pathology.

Explanation:

Sacroiliac joint pathology accounts for 15% of lower back pain, and the sacroiliac joint is
one of the most common sites of referred pain. Patients with sacroiliac joint pathology
commonly experience pain above the posterior buttock and seldom have focal
neurological deficits. Physical examination tests are poor predictors of sacroiliac joint
pathology.

18) Typical histologic features of an osteoid osteoma include all of the following
except:
(A) Chondrocytes in an arrangement similar to that of a physis
(B) Nidus composed of haphazardly arranged network of osteoid trabeculae
(C) Varying degrees of mineralization with greatest mineralization in the center of the lesion
(D) Osteoblasts rimming the trabeculae
(E) Vascularized spindle cell stroma
Explanation:

The histologic features of an osteoid osteoma include the following:

 Nidus composed of haphazardly arranged network of osteoid trabeculae

 Varying degrees of mineralization with greatest mineralization in the center of the lesion
 Loose fibrovascular connective tissue between trabeculae
o Osteoblasts rimming the trabeculae

o Vascularized spindle cell stroma

19) When an osteoblastoma occurs in the spine, it can involve all of the following
except:
(A) Facets
(B) Transverse processes
(C) Pedicles
(D) Lamina
(E) Vertebral body

Explanation:

When an osteoblastoma occurs in the spine, involvement of the posterior elements of the
vertebra is typical and includes:

 Lamina
 Pedicles
 Transverse processes
 Facets

 Rib heads adjacent to thoracic vertebrae

20) A 17-year-old high school football player presents to the emergency department
after being removed from play following a harsh tackle. The patient reports a
sharp burning and stinging pain through his left arm that has not resolved since
the tackle. A careful history revealed that this is the fourth episode of burning
and stinging pain. In each episode of pain, the symptoms have lasted longer
than the previous episode. The patient also reports that he has suffered from
two prior episodes of transient weakness and numbness in all extremities
following harsh tackles. Which of the following statements concerning this
patient is correct:
(A) There is no contraindication to return to play in this patient.
(B) There is a relative contraindication to return to play in this patient.
(C) There is an absolute contraindication to return to play in this patient.
(D) Because this patient has suffered repeated episodes of transient pain after tackles, he is obviously experienced enough to not
need education and counseling to help prevent recurrence.
(E) The patient should not participate in football games, but should feel free to continue lifting weights and practicing.

Explanation:

It is important to understand the current return to play criteria for cervical spine injuries in athletes. There is an absolute contraindication
to return to play in patients who have: a) more than two previous episodes of transient quadriparesis/quadriplegia, b) clinical history,
physical examination findings, or imaging confirmation of cervical myelopathy/myelomalacia, and c) continued cervical neck discomfort,
decreased range of motion, or any evidence of a neurologic deficit from baseline after any cervical spine injury. Patient education and
follow-up are always indicated in patients with burners and stingers. This patient should not participate in football games, exercise, or
practice until full mobility and strength has returned, and all neurologic symptoms have resolved.
1. D

2. D

3. C

4. A

5. D

6. E

7. E

8. B

9. C

10. D

11. D

12. D

13. C

14. E

15. B

16. C

17. A

18. A

19. E

20. C