CCOC dag 2

Question 1

1. A 50 year old lady suffer from back pain who
   worsens in extension. The best therapy is
2. extension based therapy
3. flexion based therapy
4. core strengthening
5. aerobic training
6. spine surgery.

Answer 1

2. flexion based therapy

Question 2

2. A 60 year old farmer suffers from low back pain. MRI
   show black disc on several levels. The most important
   pain generator of low back pain is believed to be
3. facet joints
4. discogenic
5. sacro iliac joint
6. nerve roots
7. muscle thigtness

Answer 2

.

Question 3

3. A 65 year old pensionado suffers from heavy midline back pain, X ray shows a severe facet joint artritis. The following is CORRECT about facet joint innervation
4. facet joints are innervated by the medial branch of
   the dorsal ramus after it exits the neuroforamen
   above and at the level of the facet
5. Facet joints are innervated by the lateral branch of
   the dorsal ramus after it exits the neuroforamen above and at the level of the facet
6. Facet joints are not innervated
7. Facet joints are innervated by the medial branch
   of the dorsal ramus after it exits the neuroforamen below the level of the facet
8. Facet joints are innervated by the medial branch
   of the dorsal ramus after it exits the neuroforamen above and at the level of the facet

Answer 3

5. Facet joints are innervated by the medial branch

of the dorsal ramus after it exits the neuroforamen above and at the level of the facet

Question 4

4. The use of an EMG in the diagnosis of myelopathy is
5. positive only if ventral gray matter containing α motor neurons is affected
6. to evaluate the motor unit at rest for spontaneous muscle activity
7. positive by the abcence of fasciculations indicating upper motor neuron disease
8. to test pain fibers
9. positive when it differs from a polyradicular picture

Answer 4

1. positive only if ventral gray matter containing α motor neurons is affected

Question 5

5. In individuals older than 60 years of age
6. 41% will have abnormal MRI scans
7. 21% will have herniated discs
8. abnormal findings are not present in almost all people older than age 60 years
9. 30% will have osteoporotic fractures
10. low back pain is the leading cause of disability

Answer 5

2. 21% will have herniated discs

Question 6

6. A 45 year old worker suffers from a throracic disc
   herniation at level T8-T9 Thoracic disc herniation (TDH)
7. represent 10%-20% of cases of symptomatic herniated discs
8. most occur in the caudal third of the thoracic spine
9. more men than women are affected
10. mostly individuals from 20-30 years of age are affected
11. central herniations are easier to acces via a posterior approach

Answer 6

2. most occur in the caudal third of the thoracic spine

Question 7

7. A 53-year-old female complained of progressive radiating pain into her both legs with mild low back pain. Her walking distance was reduced to 100 m, after which she had to stop and lean forward or sit down. Physical
   examination and MRI illustrated spinal stenosis at L4/5.
   Which of the following answers is true
8. when the spine is in flexion the spinal canal
   diameter diminishes
9. the symptoms usally start proximally and
   progress distally
10. in most patient with lumbar stenosis
    weakness, numbness and reflex abnormalities occur
11. laminectomy with fusion is the golden
    standard in surgery

Answer 7

2. the symptoms usally start proximally and

progress distally

Question 8

8. Mostly acute low back pain disapears within 6 weeks.
   Although its mostly self-limiting a clinician should always
   maintain an awareness of red flags that signify serious
   conditions.which of the following is NOT a red flag sign?
9. night pain or pain at rest
10. persistent fever
11. urinary incontinence or retention
12. saddle anesthesia
13. ability to walk for three hours

Answer 8

5. ability to walk for three hours

Question 9

9. A ‘vacuum disk’ seen on conventional radiograms of
   CT scans of lumbar spine is:
10. A sign of degenerative disk
11. A sign of active infection in the disk space
12. Should be examined with diskogram and cultures to rule out infection
13. Pathognomonic of spinal tuberculosis
14. Is associated with a psoas abscess

Answer 9

1. A sign of degenerative disk

Question 10

10. A 71 years-old female is admitted to the hospital with spontaneous acute and severe back pain. Her CRP and ESR are elevated and the MRI scan is consistent with the diagnosis of diskitis L3-L4. In her medical history only a successfully treated Graves disease with normalized thyroid levels 30 years ago. She uses no medications and did not undergo a medical or surgical intervention recently. Which of the following conditions should be ruled out as a source of diskitis?
11. Rheumatoid arthritis
12. Thyroid cancer
13. Endocarditis
14. Spinal stenosis
15. COPD

Answer 10

3. Endocarditis

Question 11

11. In which of the following conditions is there an
    absolute contraindication to the use of spinal implants?
12. Pyogenic diskitis with MRSA
13. Spinal tuberculosis
14. Epidural abscess with e. coli
15. Fungal infection of the vertebral body
16. None of the above

Answer 11

5. None of the above

Question 12

12. Which of the following statements about epidural
    infections is false?
13. Epidural abscesses should always be drained surgically
14. The majority of epidural infections are caused by s. aereus
15. Epidural infections may cause neurologic deficits
16. Epidural abscess can result from extension of vertebral osteomyelitis or diskitis
17. Epidural abscess can also be caused by a
    granulomatous infection

Answer 12

1. Epidural abscesses should always be drained surgically

Question 13

13. The most common reason for missing a spinal
    fracture is:
14. Inadequate radiologic examination
15. Multiple extremity injuries
16. Sedation of the patient at the site of trauma
17. Intoxication with alcohol or drugs
18. Lack of MRI facilities at the initial hospital

Answer 13

1. Inadequate radiologic examination

Question 14

14. A 75 year-old man known with DM Type II is presented at the ER with back pain after a fall at home from standing height. Neurologic exam is normal. On
    CR of cervical, thoracic and lumbar spine no fractures are seen. Extensive bone bridges between multiple vertebrae are noticed at the cervical, thoracic and
    thoracolumbar junction. What is the proper next step?
15. Analgesics and outpatient control in one week
16. A Jewett brace and proper analgesics and follow up by the GP
17. Admission to the hospital for clinical mobilization
18. CT or MRI of the whole spine to rule out spinal fracture
19. Appointment for osteoporosis screening with DEXA scan

Answer 14

4. CT or MRI of the whole spine to rule out spinal fracture

Question 15

15. Type A injuries in subaxial cervical and
    thoracolumbar spine:
16. Are always stable injury patterns
17. Never cause spinal cord injury
18. Are a cause of severe acute mechanical instability
19. Imply intact posterior tension band
20. Are associated with AIS-A functional
    outcomes

Answer 15

4. Imply intact posterior tension band

Question 16

16. Which of the following statements about the
    compression fractures of C1 (atlas) is false?
17. Majority can be treated conservatively
18. About 10% of all cervical injuries
19. Cause frequently neurologic injury
20. In almost half of the cases there is a concomitant C2 fracture
21. Can be unstable if transverse ligament is injured

Answer 16

.

Question 17

17. Concerning osteoporosis of the spine the bone
    mineral density (BMD), which of the following
    statement is FALSE:
18. BMD decrease with age
19. BMD peaks between 25 and 30 years of age
20. BMD declines 6% per year in women during the first postmenopausal decade
21. BMD correlates strongly with bone strength
22. BMD below 2.5sd the mean young adult is defined osteoporosis (WHO)

Answer 17

.

Question 18

18. Osteoporotic spinal fracture is associated with?
    Which of the following statements is FALSE:
19. Declines in predicted forced vital capacity
20. Prior compression fracture
21. Thinned cortices
22. 2 – years mortality in these patients is 5 times that of the unaffected population
23. Reduced BMD

Answer 18

4. 2 – years mortality in these patients is 5 times that of the unaffected population

Question 19

19. The spine is a frequent site of bone tumors. In daily practice it can be difficult to distinguish an osteoporotic spine lesion from spinal tumor. Specific diagnostic characteristics can be more common in spinal tumors than in osteoporotic fractures. Which of the following statements is FALSE
20. Blastic or lytic apprearance
21. Cortical involvement is less discrete
22. Pedicular involvement
23. Soft-tissue masses
24. Below T5 level

Answer 19

5. Below T5 level

Question 20

20. A 70 year old women with spontaneous and continuous thoracic pain for 4 months without neurological deficit. No symptoms of fever or failure to thrive. Lab: BSE 80 mm/u CRP 24u leucocyts 9.5 10*9. A MRI and Xray were performed (see figure 1 and 2): multiple bone lesions lesion at the vertebral body of
    th10,11,12. The radiological diagnosis is most likely:
21. Multiple Myeloma
22. Osteoporosis
23. Chronic Osteomyelitis
24. Fibrous dysplasia
25. Osteoartritis

Answer 20

1. Multiple Myeloma

Question 21

21. Most frequently a C8 radiculopathy is caused by…..
22. a contained herniated disc
23. an extruded herniated disc
24. nerve root inflammation
25. brachial plexus problems
26. osteophytes at the end-plate

Answer 21

5. osteophytes at the end-plate

Question 22

22. Which of the following myelopathy signs doesn’t belong
    to a cervical spondylotic myelopathy (CSM)?
23. Babinski Reflex
24. Absent Knee Tendon Reflex
25. Spastic Walking Pattern
26. Tetraplegia
27. Paraplegia

Answer 22

2. Absent Knee Tendon Reflex

Question 23

23. The main physiological causative mechanism spinal cord compression leading to cervical spondylotic myelopathy (CSM) is…
24. A cervical herniated disc
25. Collapsed discs
26. Arthrosis of facet joints
27. Flaval ligament hypertrophy
28. All of the above

Answer 23

5. All of the above

Question 24

24. The standard surgical method for most patients with
    cervical spondylotic myelopathy is…
25. ACDF
26. Multi-level ACDF
27. Multilevel ACDF + plate/screw fixation
28. Cervical Laminectomy
29. Cervical Laminectomy + lateral mass fixation

Answer 24

4. Cervical Laminectomy

Question 25

25. Adolescent idiopathic scoliosis: treatment 1. Treatment by brace is obsolete 2. Brace treatment aims to halt progression of the curve 3. Surgical stabilisation should be delayed as long as possible, at least to the end of growth, to allow the spine to grow 4. An instrumented fusion wit a Harrington rod still forms the golden standard 5. The current standard of surgical care includes the wake up test to detect neurologic injury

Answer 25

2. Brace treatment aims to halt progression of the curve

Question 26

26. Congenital scoliosis 1. Has a polygenetic inheritance 2. Is associated with congenital heart defects in 10% of patients 3. Failure of formation leads to a benign form of scoliosis 4. Failure of segmentation leads to a scoliosis with the convexity on the opposite side to the segmentation defect 5. Treatment by brace is mildly effective

Answer 26

4. Failure of segmentation leads to a scoliosis with the convexity on the opposite side to the segmentation defect

Question 27

27. Spondylolysis and spondylolisthesis in children | (

Answer 27

1. The incidence is 5-10%

Question 28

28. Operative treatment (instrumented fusion) of adult de novo degenerative scoliosis 1. Osteoporosis does not play a significant role in the operative management 2. Surgery is rarely effective in improving Quality of Life 3. Late complications of surgery are rare 4. Should be aimed at improving the sagital balance more than the coronal balance 5. Should not include fusion to the sacrum/pelvis

Answer 28

4. Should be aimed at improving the sagital balance more than the coronal balance

Question 29

29. A 65-years old female patient with seropositive rheumatoid arthritis is planned for total hip arthroplasty (THA) under general anaesthesia. Lateral flexion-extension radiographs of the asymptomatic cervical spine are considered to assess: 1. Atlanto-axial subluxation 2. Cranial settling 3. Subaxial subluxation 4. A combination of A,B,C 5. Radiographs of the cervocal spine are not necessary in THA surgery

Answer 29

4. A combination of A,B,C

Question 30

30. A 45 year-old man with Ankylosing Spondylitis presents with progressive back pain without neurological deficit. Plain radiographs show a discovertebral lesion T10-T11. The diagnostic and treatment policy includes: 1. Spinal instrumentation and fusion, biopsy and culture 2. Spinal instrumentation and fusion, no biopsy, no culture 3. Biopsy, culture and antibiotic treatment 4. Biopsy, culture and plaster immobilisation 5. Plaster immobilisation

Answer 30

.

Question 31

31. A patient with alcohol abuse is presented at the A&E department with only minor complains of his cervical spine after a fall from a chair. AP and lateral radiographs of the cervical spine does not shows any fractures. The next step in the assessment or treatment is: 1. Sent him home 2. Clinical observation 3. Philadelphia collar 4. Additional CT imaging 5. Additional MRI

Answer 31

4. Additional CT imaging

Question 32

32. Radiological diagnostic criteria of a patient with Diffuse idiopathic skeletal hyperostosis (DISH) are. Which statement is wrong? 1. SI joint erosions/fusion 2. Anterolateral flowing calcification 3. Anterolateral ossification > 4 vertebral bodies 4. Preservation of intervertebral disc height 5. Absence of degenerative disc disease

Answer 32

1. SI joint erosions/fusion