A 50-year-old man presents to your office with complaints of arm pain. On examination, he has loss of sensation over the lateral aspect of the arm, and weakness with shoulder abduction. What is the expected deep tendon reflex deficit expected in this patient?

1. 
   

   Biceps reflex.

   
   
2. 
   

   Triceps reflex.

   
   
3. 
   

   Brachioradialis reflex.

   
   
4. 
   

   Hoffman’s sign/reflex.

Which of the following is true?

1. 
   

   The myelin sheath is a fatty insulating layer around the cell body that facilitates saltatory conduction.

   
   
2. 
   

   The nodes of Ranvier are interruptions in the myelin sheath that contain a large number of voltage-gated sodium and potassium channels.

   
   
3. 
   

   The dendrites receive signals from the cell body and transfer those signals to other neurons.

   
   
4. 
   

   Schwann’s cells myelinate neurons of the central nervous system.

Which of the following is not a presentation of a UMN lesion?

1. 
   

   Increased reflexes.

   
   
2. 
   

   Spasticity.

   
   
3. 
   

   Fasciculations.

   
   
4. 
   

   Babinski’s sign.

a is correct. This patient’s presentation is consistent with C5 radiculopathy, which is associated with deficiencies in the biceps reflex. The C5–C6 nerve roots comprise the neural pathway for the biceps reflex.

b is correct. The myelin sheath is a fatty insulating layer around the axon. Dendrites receive signals from other neurons and transmit them to the cell body. Oligodendrocytes myelinate neurons of the central nervous system.

c is correct. Fasciculations are an LMN sign. The other findings are consistent with UMN pathology.

Which of the following is not true regarding spinal nerve roots?

1. 
   

   C1–C7 spinal nerves exit below the corresponding vertebrae.

   
   
2. 
   

   Spinal nerves exit the spinal canal via the intervertebral foramina.

   
   
3. 
   

   There a total of 31 spinal nerves.

   
   
4. 
   

   The spinal cord terminates at the conus medullaris (L2).

Which of the following is the correct pairing of spinal tract and site of decussation?

1. 
   

   Anterior corticospinal: anterior white commissure.

   
   
2. 
   

   Rubrospinal: none (ipsilateral innervation).

   
   
3. 
   

   Tectospinal: none (ipsilateral innervation).

   
   
4. 
   

   Medial vestibulospinal: midbrain.

Which of the following is not true regarding intervertebral disks?

1. 
   

   The intervertebral joint space is not a synovial joint.

   
   
2. 
   

   The most cephalad disk is located between C2 and C3.

   
   
3. 
   

   The nucleus pulposus surrounds the annulus fibrosis.

   
   
4. 
   

   They are composed of primarily type I and II collagens.

a is correct. C1–C7 vertebrae exit above their corresponding vertebrae.

a is correct. Nerve fibers of the anterior corticospinal tract decussate at the anterior white commissure, which is located in the anterior portion of the midline of the spinal cord. The rubrospinal and tectospinal tracts decussate at the midbrain. The medial vestibulospinal tract decussates at the caudal medulla.

c is correct. The annulus fibrosis is surrounded by the nucleus pulposus. All the other choices are true statements.

Which of the following branches of the vertebral artery supplies the odontoid process of C2?

1. 
   

   Anterior spinal artery.

   
   
2. 
   

   Posterior spinal artery.

   
   
3. 
   

   Posterior ascending artery.

   
   
4. 
   

   Anterior segmental medullary artery.

A 55-year-old man comes into the office complaining of axial neck pain of 6 months’ duration. On physical examination, decreased sensation of the upper occiput and scalp is noted. Pathology of which joint space is most likely to be demonstrated on radiographic examination?

1. 
   

   Atlanto-occipital junction.

   
   
2. 
   

   C1–C2 disk space.

   
   
3. 
   

   C2–C3 disk space.

   
   
4. 
   

   Both atlanto-occipital junction and the C1–C2 disk space.

A 50-year-old woman presents to the emergency room following a motor vehicle accident. On radiographic examination, instability is noted between the atlantoaxial joint with increased space between the anterior arch of the atlas and the dens. Which ligament is most likely injured?

1. 
   

   Alar ligament.

   
   
2. 
   

   Barkow’s ligament.

   
   
3. 
   

   Nuchal ligament.

   
   
4. 
   

   Tectorial membrane.

   
   
5. 
   

   Cruciate ligament.

c is correct. The posterior ascending arteries connect to form the apical arcade at the top of the odontoid process and aid in collateral circulation of the dens with the anterior ascending arteries.

b is correct. The C2 nerve root is likely affected in this individual, resulting in decreased sensation of the scalp. In the cervical vertebrae above C7, all nerve roots exit above the respective vertebrae. As such, the C2 nerve root will be exiting between the C1–C2 disk space, and significant pathology here will result in impingement of this nerve root.

e is correct. The cruciate ligament maintains the stability of craniocervical junction by locking the odontoid process against the anterior arch of C1. This middle pivot joint provides the axis for rotation at the atlantoaxial joint.

A 30-year-old motorcyclist is involved in an accident on the highway. Following evaluation, he is diagnosed with superior brachial plexus injury. Which of the following would likely be normal on his physical examination?

1. 
   

   Shoulder abduction.

   
   
2. 
   

   Flexion of the elbow.

   
   
3. 
   

   Sensation over the radial aspect of the forearm.

   
   
4. 
   

   Sensation of the third digit of the hand.

   
   
5. 
   

   Sensation over the lateral aspect of the shoulder.

Which of the following statements is true?

1. 
   

   All subaxial cervical vertebrae have transverse foramens in a majority of patients.

   
   
2. 
   

   Range of rotation is least at more cranial levels.

   
   
3. 
   

   As one moves cranially, superior articular facets transition toward posterolateral orientation.

   
   
4. 
   

   The vertebral artery can be found in the transverse foramen of all cervical vertebrae.

A 50-year-old man presents with left arm pain lasting 4 weeks. The pain is distributed over the anterior surface of his upper arm and forearm. What would be the likely motor deficit and level of nerve root compression on this patient?

1. 
   

   Flexion of forearm with nerve root compression at the C5–C6 disk level.

   
   
2. 
   

   Abduction of arm with nerve root compression at the C5–C6 disk level.

   
   
3. 
   

   Extension of forearm with nerve root compression at the C6–C7 disk level.

   
   
4. 
   

   Abduction of arm with nerve root compression at the C4–C5 disk level.

   
   
5. 
   

   Flexion of the wrist with nerve root compression at the C6–C7 disk level.

d is correct. The patient has experienced a C5–C6 root avulsion. They will experience loss of shoulder abduction and sensation of the lateral shoulder (axillary nerve), biceps weakness, and decreased sensation over the radial aspect of the forearm (musculoskeletal nerve–lateral antebrachial cutaneous nerve).

a is correct. The vertebral artery enters the transverse foramen at C6; however, in most patients’ vertebrae, C3–C7 exhibit a transverse foramen.

d is correct. Based on dermatomal distribution, this patient is exhibiting C5 sensory deficit, which corresponds with a weakness in arm abduction (C5 primary motor innervation is the deltoid). In the cervical vertebrae, each nerve root exits above its corresponding level (C5 nerve root exits above C6 vertebrae at the C5–C6 disk level).

Which of the following thoracic vertebrae exhibits the narrowest pedicle diameter?

1. 
   

   T1.

   
   
2. 
   

   T3.

   
   
3. 
   

   T6.

   
   
4. 
   

   T7.

   
   
5. 
   

   T12.

At which level does the artery of Adamkiewicz typically arise?

1. 
   

   T1.

   
   
2. 
   

   T3.

   
   
3. 
   

   T6.

   
   
4. 
   

   T7.

   
   
5. 
   

   T9.

In order to prevent early instrumentation failure, spinal fusion constructs should not end at which level?

1. 
   

   T4–T5.

   
   
2. 
   

   T5–T6.

   
   
3. 
   

   T6–T7.

   
   
4. 
   

   T7–T8.

   
   
5. 
   

   T9–T10.

c is correct. The thoracic pedicles are widest at T1 and T12, and gradually become narrower as one progresses toward the middle of the spinal column (T6).

e is correct. The artery of Adamkiewicz typically arises from left posterior intercostal artery between T9 and T12 in 85% of individuals.

d is correct. The apex of thoracic kyphosis exists at T7–T8. Instrumentation ending at the thoracic kyphotic apex can lead to early instrumentation failure.

A patient presents to your clinic with weakness in knee extension, decreased patellar reflex, and cutaneous sensory loss along the lower anterior thigh, knee, anterior lower leg, and medial ankle. Which nerve root is likely affected?

1. 
   

   L2.

   
   
2. 
   

   L3.

   
   
3. 
   

   L4.

   
   
4. 
   

   L5.

Which of the following statements is true?

1. 
   

   The psoas muscles lie lateral to the lumbar vertebrae.

   
   
2. 
   

   The genitofemoral nerve courses along the iliacus muscle.

   
   
3. 
   

   The abdominal aorta bifurcates at the L5 vertebral level.

   
   
4. 
   

   The obturator nerve arises from the L2–L3 levels.

Which of the following is not true regarding lumbar ligamentous anatomy?

1. 
   

   The ligamentum flavum spans from the posterior aspect of the inferior lamina to the anterior aspect of the superior lamina.

   
   
2. 
   

   The posterior longitudinal ligament limits spine extension and secures intervertebral disks.

   
   
3. 
   

   The supraspinous ligament terminates at L3.

   
   
4. 
   

   The interspinous ligament connects the spinous processes and is oriented obliquely.

c is correct. L4 provides motor innervation to the anterior thigh and along the dermatome described. The disk herniation at the L3–L4 level would compress L4.

a is correct. The genitofemoral nerve courses along the psoas major muscles, the abdominal aorta bifurcates at L4, and the obturator nerve arises from L2 to L4.

b is correct. The posterior longitudinal ligament limits spine flexion and secures the intervertebral disks.

A 25-year-old female gymnast sustains an injury during a fall from the uneven bars. Following evaluation, she is diagnosed with an S3 and S4 nerve lesion. Which of the following would likely be limited for the patient?

1. 
   

   External rotation of the femur, extension, and lateral stabilization of the left hip.

   
   
2. 
   

   Voluntary control over the anal sphincter.

   
   
3. 
   

   External rotation, abduction, and extension of the left hip joint.

Which of the following statements is true?

1. 
   

   The dural sac ends at S2 and continues to the coccyx as the sacrospinous ligament.

   
   
2. 
   

   The nerve to the obturator internus supplies motor innervation to both the obturator internus and the inferior gemellus.

   
   
3. 
   

   The sacral plexus is located between the pelvic (Waldeyer’s) fascia and piriformis.

   
   
4. 
   

   The apex of the sacrum articulates with the final lumbar vertebrae.

A 40-year-old man presents with diminished ankle plantar flexion and sensation over the posterior surface of his right thigh. Impingement of which of the following nerve roots could result in this presentation?

1. 
   

   L5.

   
   
2. 
   

   S1.

   
   
3. 
   

   S2.

   
   
4. 
   

   a and b.

   
   
5. 
   

   b and c.

   
   
6. 
   

   All of the above.

b is correct. The pudendal nerve, which provides motor innervation to the external anal sphincter, receives contributions from S2, S3, and S4. a is incorrect because the function described can be attributed to the gluteus maximus, which is innervated by the inferior gluteal nerve (L5, S1, S2). c is incorrect because this is the function of the piriformis, which is innervated by the nerve to the piriformis (L5, S1, S2).

c is correct. The sacral plexus lies deep to the pelvic fascia and superior to the piriformis. a is incorrect because the dural sac continues as the coccygeal ligament. b is incorrect because the nerve to the obturator internus supplies the superior gemellus. d is incorrect because the superior articular process, located at the base of the sacrum, articulates with the final lumbar vertebrae.

e is correct. The posterior cutaneous femoral nerve, responsible for sensation to the posterior surface of the thigh and leg, receives contributions from S1, S2, and S3. While S2 is the predominant nerve root in this dermatome, injury to any of these sacral roots can affect the posterior cutaneous nerve’s function. Active ankle plantar flexion is predominantly innervated by the S1 nerve root.

Which of the following examination findings would most likely be present in a patient with myelopathic symptoms?

1. 
   

   Reproduction of a patient’s radicular pain when rotating and laterally flexing head to one side and then providing an axial load.

   
   
2. 
   

   Absent sphincter reflex when squeezing patient’s glans penis or clitoris or tugging on indwelling Foley catheter, monitoring for anal external sphincter contraction.

   
   
3. 
   

   Patient unable to perform at least 20 cycles of grip/release within 10 seconds when patient asked to rapidly make a fist and release with both hands.

   
   
4. 
   

   Negative sitting root test with positive straight leg raise.

   
   
5. 
   

   Patient is unable to maintain balance when asked to stand up with their feet together and eyes closed for 10 seconds.

Which of the following is an incorrect pairing of nerve root and examination?

1. 
   

   C5 – lateral shoulder sensation – deltoid muscle – biceps reflex.

   
   
2. 
   

   C6 – lateral arm/forearm sensation – biceps muscle – triceps reflex.

   
   
3. 
   

   L4 – lower anterior thigh sensation – tibialis anterior muscle – patellar tendon reflex.

   
   
4. 
   

   L5 – posterolateral thigh and lateral leg sensation – extensor hallucis longus muscle – medial hamstring reflex (rare).

   
   
5. 
   

   S1 – lateral foot, lateral posterior thigh, and leg sensation – gastrocnemius muscle – Achilles’ reflex.

Patients with spinal stenosis often present with what type of gait:

1. 
   

   Forward leaning.

   
   
2. 
   

   Trendelenburg gait.

   
   
3. 
   

   Antalgic gait.

   
   
4. 
   

   Circumduction gait.

   
   
5. 
   

   High-steppage gait.

c is correct. The grip and release test is an appropriate test for the assessment of cervical myelopathy. Reproduction of radicular pain with rotation and flexion of the head is the Spurling’s test, which is an assessment for cervical radiculopathy. Absent sphincter reflexes when squeezing the glans penis is indicative of damage to the conus medullaris or sacral nerve roots. Negative sitting root test implies a nonorganic pathology of a patient’s lumbar symptoms. Inability to maintain balance when standing with eyes closed indicates injury to the dorsal column of the spinal cord.

b is correct. C6 provides lateral forearm to thumb sensation, motor innervation to the biceps, and the brachioradialis reflex.

a is correct. Forward leaning helps increase the space within the spinal canal, diminishing symptoms for patients experiencing spinal stenosis. Trendelenburg gait is exhibited by patients with gluteus medius weakness. Antalgic gait is predominant in patients experiencing pain with weight bearing, such as those with hip arthritis. Circumduction gait indicates upper motor neuron pathology, such as a previous stroke. High-steppage gait indicates L4 nerve root or deep peroneal nerve palsy.