Deck 16: The Vertebral Column, the Spinal Cord, and the Meninges

Question 1

An 11 -year-old boy was showing off in front of friends by diving into the shallow end of a swimming pool. After one particularly daring dive, he surfaced quickly and climbed out of the pool, holding his head between his hands. He said that he had hit the bottom of the pool with his head and now had severe pain in the root of the neck, which was made worse when he tried to move his neck. A lateral radiograph revealed that the right inferior articular process of the fifth cervical vertebra was forced over the anterior margin of the right superior articular process of the sixth cervical vertebra, producing a unilateral dislocation with nipping of the right sixth cervical nerve.

-The following symptoms and signs confirmed the diagnosis except which?

A) The head was rotated to the right.
B) There was spasm of the deep neck muscles on the right side of the neck, which were tender to touch.
C) The patient complained of severe pain in the region of the back of the neck and right shoulder.
D) The slightest movement produced severe pain in the right sixth cervical dermatome.
E) The large size of the vertebral canal in the cervical region permitted the spinal cord to escape injury.

Answer 1

The head was rotated to the right.

Question 2

A 50-year-old coal miner was crouching at the mine face when a large rock suddenly became dislodged from the roof of the mine shaft and struck him on the upper part of his back. The emergency department physician suspected a displacement of the upper thoracic spines on the sixth thoracic spine.

-The following physical signs confirmed a diagnosis of fracture dislocation between the fifth and sixth thoracic vertebrae except which?

A) A lateral radiograph revealed fractures involving the superior articular processes of the sixth thoracic vertebra and the inferior articular processes of the fifth thoracic vertebra.
B) Considerable forward displacement of the body of the fifth thoracic vertebra on the sixth thoracic vertebra occurred.
C) The patient had signs and symptoms of spinal shock.
D) The large size of the vertebral canal in the thoracic region leaves plenty of space around the spinal cord for bony displacement.
E) The patient later showed signs and symptoms of paraplegia.

Answer 2

The large size of the vertebral canal in the thoracic region leaves plenty of space around the spinal cord for bony displacement.

Question 3

A 66-year-old woman was seen in the emergency department complaining of a burning pain over the upper part of her right arm. The pain had started 2 days previously and had progressively worsened. Physical examination revealed weakness and wasting of the right deltoid and biceps brachii muscles. The patient also had hyperesthesia in the skin over the lower part of the right deltoid and down the lateral side of the arm. Radiologic examination showed extensive spur formation on the bodies of the fourth, fifth, and sixth cervical vertebrae. These signs and symptoms suggested severe osteoarthritis of the cervical vertebral column.

-This disease produced the following changes in the vertebrae and related structures except which?

A) Repeated trauma and aging had resulted in degenerative changes at the articulating surfaces of the fourth, fifth, and sixth cervical vertebrae.
B) Extensive spur formation resulted in narrowing of the intervertebral foramina with pressure on the nerve roots.
C) The burning pain and hyperesthesia were caused by pressure on the third and fourth cervical posterior roots.
D) The weakness and wasting of the deltoid and biceps brachii muscles were caused by pressure on the fifth and sixth cervical anterior roots.
E) Movements of the neck intensified the symptoms by exerting further pressure on the nerve roots.
F) Coughing or sneezing raised the pressure within the vertebral canal and resulted in further pressure on the roots.

Answer 3

The burning pain and hyperesthesia were caused by pressure on the third and fourth cervical posterior roots.

Question 4

A medical student offered to move a grand piano for his landlady. He had just finished his final examinations in anatomy and was in poor physical shape. He struggled with the antique monstrosity and suddenly experienced an acute pain in the back, which extended down the back and outer side of his left leg. On examination in the emergency department, he was found to have a slight scoliosis with the convexity on the right side. The deep muscles of the back in the left lumbar region felt firmer than normal. No evidence of muscle weakness was present, but the left ankle jerk was diminished.

-The symptoms and signs of this patient strongly suggest a diagnosis of prolapsed intervertebral disc except which?

A) The pain was the worst over the left lumbar region opposite the fifth lumbar spine.
B) The pain was accentuated by coughing.
C) With the patient supine, flexing the left hip joint with the knee extended caused a marked increase in the pain.
D) A lateral radiograph of the lumbar vertebral column revealed nothing abnormal.
E) A magnetic resonance imaging study revealed the presence of small fragments of the nucleus pulposus that had herniated outside the anulus in the disc between the fifth lumbar vertebra and the sacrum.
F) The pain occurred in the dermatomes of the third and fourth lumbar segments on the left side.

Question 5

When performing a lumbar puncture (spinal tap) on an adult, the following anatomic facts have to be taken into consideration except which?

A) With the patient in the lateral prone or upright sitting position, the vertebral column should be well flexed to separate the spines and laminae of adjacent vertebrae.
B) An imaginary line joining the anterior superior iliac spines passes over the fourth lumbar spine.
C) The needle should be inserted above or below the fourth lumbar spine.
D) To enter the subarachnoid space, the needle will pass through the skin, superficial fascia, supraspinous ligament, interspinous ligament, ligamentum flavum, areolar tissue (containing the internal vertebral venous plexus), dura mater, and arachnoid mater.
E) The spinal cord ends below in the adult at the level of the lower border of the first lumbar vertebra.
F) With the patient in the lateral prone position, the normal cerebrospinal fluid pressure is about $60-150$ $\mathrm{mm} \mathrm{H}_{2} \mathrm{O}$ .

Question 6

A 22-year-old student was driving home from a party and crashed his car head on into a brick wall. On examination in the emergency department, he was found to have a fracture dislocation of the seventh thoracic vertebra, with signs and symptoms of severe damage to the spinal cord.

-On recovery from spinal shock he was found to have the following signs and symptoms except which?

A) Upper motor neuron paralysis of his left leg
B) A band of cutaneous hyperesthesia extending around the abdominal wall on the left side at the level of the umbilicus, which was caused by the irritation of the cord immediately above the site of the lesion
C) On the right side, total analgesia, thermoanesthesia, and partial loss of tactile sense of the skin of the abdominal wall below the level of the umbilicus involving the whole of the right leg
D) Fracture dislocation of the seventh thoracic vertebra, which would result in severe damage to the seventh thoracic segment of the spinal cord
E) Unequal sensory and motor losses on the two sides, which indicate a left hemisection of the spinal cord

Question 7

A 45-year-old woman visited her physician because of a low back pain of 3 months' duration. She was otherwise very fit. On examination of her back, nothing abnormal was discovered. The physician then listened to her chest, examined her thyroid gland, and finally examined both breasts. A large, hard mass was found in the left breast.

-The following facts support the diagnosis of carcinoma of the left breast with secondaries in the vertebral column except which?

A) The lump in the breast was painless and the patient had noticed it while showering 6 months previously.
B) Several large, hard, pectoral lymph nodes were found in the left axilla.
C) A lateral radiograph of the lumbar vertebral column showed extensive metastases in the bodies of the second and third lumbar vertebrae.
D) The lump was situated in the upper outer quadrant of the left breast and was fixed to surrounding tissues.
E) Although the cancer had spread by the lymph vessels, no evidence of spread via the bloodstream was present.

Question 8

A 75-year-old woman was dusting the top of a high closet while balanced on a chair. She lost her balance and fell to the floor, catching her right lumbar region on the edge of the chair.

-The following statements about this patient are correct except which?

A) Examination of the back revealed a large bruised area in the right lumbar region, which was extremely tender to touch.
B) Anteroposterior and lateral radiographs exclude the presence of a fracture, especially of a transverse process.
C) A 24-hour specimen of urine should be examined for blood to exclude or confirm injury to the right kidney.
D) Careful examination of the erector spinae muscles or quadratus lumborum muscle may reveal extreme tenderness and therefore injury to these muscles.
E) A lumbar puncture (spinal tap) should always be performed in back injuries to exclude damage to the spinal cord.