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OR6.1 | Degenerative Spine Disorders — Graded Quiz
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A 40-year-old man presents with sudden-onset severe low back pain after lifting a heavy carton. He has sciatica down the right leg to the heel and lateral foot. SLR is positive at 30° on the right; ankle jerk is absent on the right. He can stand on his tiptoe on the right but cannot walk on his heels. MRI shows a large right paracentral L5–S1 disc prolapse. Which nerve root is compressed?
Correct. L5–S1 disc prolapse compresses S1: absent ankle jerk, plantar flexion weakness (cannot walk on heels), and lateral foot/heel sensory loss. The patient CAN stand on tiptoe (plantar flexion tests S1 — but note heel walking tests ankle dorsiflexion, L4/L5 territory).
L5–S1 disc prolapse compresses the S1 nerve root. Absent ankle jerk (most reliable S1 sign), difficulty walking on heels (not tiptoe — plantar flexion weakness), and sensory loss in the lateral foot/heel/little toe confirm S1. The ability to stand on tiptoe tests plantar flexion (S1 — gastrocnemius); inability to walk on heels tests dorsiflexion (L4/L5).
Key differentiator: L5 root = absent NO reliable reflex (extensor hallucis longus weakness, dorsum foot numbness); S1 root = absent ANKLE JERK + plantar flexion weakness + lateral foot/heel numbness. L5–S1 disc = S1 root.
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A 65-year-old man presents with progressive difficulty walking over 6 months, bilateral leg weakness, and urinary urgency. He also describes bilateral calf pain when walking two blocks that is relieved by sitting or leaning forward (not by standing still). MRI shows severe multilevel lumbar canal stenosis with ligamentum flavum hypertrophy. This gait pattern is best described as:
Correct. Neurogenic claudication from lumbar canal stenosis is relieved by sitting or leaning forward (spinal flexion opens the canal), unlike vascular claudication which is relieved by standing still. The shopping cart sign (leaning forward improves symptoms) is pathognomonic.
Neurogenic claudication (from lumbar spinal stenosis) causes bilateral leg pain/weakness on walking, relieved by sitting/leaning forward (which widens the spinal canal) — not by simply standing still. Vascular claudication is relieved by standing still (stopping exercise). The 'shopping cart' posture (leaning forward) is characteristic of neurogenic claudication.
Key distinction: Vascular claudication → relieved by STANDING STILL (stopping exercise). Neurogenic claudication → relieved by SITTING or FLEXING SPINE (forward lean). Leaning-forward relief = lumbar stenosis.
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A 35-year-old woman presents with neck pain, right arm pain radiating to the middle finger, and weakness of elbow extension. Triceps reflex is absent on the right. Which disc level and nerve root are most likely involved?
Correct. C7 root (C6–C7 disc): absent triceps jerk, triceps weakness (elbow extension), and middle finger sensory loss. C6–C7 is the most common level for cervical disc prolapse.
C7 radiculopathy: pain to the middle finger (C7 dermatome), triceps weakness (elbow extension), absent triceps reflex. This arises from C6–C7 disc prolapse (the most common cervical disc level). Remember: C6-C7 → C7 root; C5-C6 → C6 root.
Cervical localisation: C5 → deltoid weakness/biceps reflex; C6 → biceps/brachioradialis reflex, lateral forearm and thumb; C7 → triceps reflex, middle finger, elbow extension; C8 → ring/little finger. Absent triceps jerk = C7.
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A 47-year-old male with known lumbar spondylosis develops acute retention of urine, faecal incontinence, perianal numbness, and bilateral leg weakness over 12 hours following a minor fall. Examination confirms saddle anaesthesia. After catheterisation, what is the definitive management?
Correct. Cauda equina syndrome requires urgent MRI confirmation followed by emergency surgical decompression. Time to surgery directly affects neurological recovery — especially bladder function. This is an orthopaedic/neurosurgical emergency.
Cauda equina syndrome (CES) constituted by saddle anaesthesia + bladder/bowel dysfunction + bilateral weakness is a surgical emergency. Urgent MRI confirms the diagnosis. Emergency surgical decompression (usually discectomy/laminectomy) should be performed as soon as possible — ideally within 24–48 hours of onset for best neurological recovery. Catheterisation is supportive, not definitive.
CES is a surgical emergency. Steroids are NOT the standard of care for CES. Epidural injections are contraindicated. Catheterisation treats the retention symptom but does not address the underlying cord/cauda equina compression.
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A 58-year-old woman presents with low back pain and sciatica for 3 months. She has been on NSAIDs and physiotherapy without improvement. MRI shows a posterolateral L4–L5 disc prolapse with moderate L5 root compression. She now has a mild foot drop (grade 3/5 ankle dorsiflexion). The next best step in management is:
Correct. Progressive neurological deficit (foot drop worsening) despite 3 months of conservative treatment is a clear indication for surgical intervention. Microdiscectomy is the gold-standard procedure, offering faster recovery and lower recurrence than open discectomy.
Indications for surgical discectomy in lumbar disc prolapse include: (1) cauda equina syndrome (emergency), (2) progressive neurological deficit despite conservative management, (3) failure of 6 weeks of conservative treatment with persistent significant disability. Progressive foot drop (grade 3/5) is a progressive neurological deficit — an indication for surgery.
The three surgical indications for disc prolapse: (1) Cauda equina syndrome — emergency; (2) Progressive neurological deficit despite conservative treatment — urgent; (3) Failed conservative therapy (>6 weeks) — elective. Foot drop developing = progressive deficit = surgery.
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A 70-year-old retired farmer presents with worsening low back pain, leg weakness, and X-ray evidence of multilevel lumbar spondylosis with 4 mm anterior slip of L4 on L5. MRI confirms moderate spinal canal stenosis. He has failed 6 months of conservative management. His ODI (Oswestry Disability Index) score is 68%. The most appropriate surgical option is:
Correct. Lumbar canal stenosis with spondylolisthesis requires decompression (laminectomy) plus stabilisation (instrumented posterolateral fusion). Decompression without fusion in the presence of a slip risks iatrogenic instability and worsening spondylolisthesis.
Lumbar canal stenosis with spondylolisthesis causing significant disability (high ODI) after failed conservative management requires surgical decompression + fusion (stabilisation). Simple laminectomy alone risks further instability. Decompressive laminectomy plus instrumented posterolateral fusion addresses both the neural compression and the mechanical instability.
Microdiscectomy is for disc prolapse, not multilevel stenosis. Laminectomy alone in the presence of a vertebral slip risks increasing instability. ACDF is for the cervical spine. Lumbar stenosis + slip = decompression + fusion.
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A 33-year-old woman presents with neck pain and a positive Spurling test on the right (reproduction of right arm pain on lateral neck compression with lateral flexion towards the affected side). What does a positive Spurling test indicate?
Correct. Spurling's test (lateral compression/foraminal compression test) is highly specific for cervical radiculopathy. A positive test reproduces radicular arm pain, confirming ipsilateral neural foraminal narrowing and nerve root compression.
Spurling's test (foraminal compression test): The examiner laterally flexes the patient's head toward the symptomatic side and applies gentle axial compression. A positive test reproduces the patient's radicular arm pain, indicating ipsilateral neural foraminal narrowing and nerve root compression. It has high specificity (>90%) for cervical radiculopathy.
Spurling's test narrows the neural foramen on the ipsilateral side. Reproducing the patient's arm pain = nerve root compression in that foramen. Sensitivity ~40–60%; specificity >90% for radiculopathy.
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A 45-year-old woman presents with right arm pain, weakness, and sensory loss in the thumb and index finger. MRI shows right C5–C6 disc prolapse with foraminal stenosis. Conservative management for 8 weeks has failed. She has no myelopathic signs. The most appropriate surgical procedure is:
Correct. ACDF is the standard surgical treatment for single-level cervical disc prolapse causing refractory radiculopathy. The anterior approach provides direct access to the disc and foramen. Fusion (with plate and cage) stabilises the segment after discectomy.
For single-level cervical disc prolapse causing radiculopathy with failed conservative management, anterior cervical discectomy and fusion (ACDF) is the gold-standard surgical procedure. It decompresses the nerve root via the anterior approach and stabilises the segment. Posterior cervical foraminotomy is an alternative for foraminal (not central) compression.
Laminoplasty is for multilevel cervical myelopathy. Posterior lumbar interbody fusion is for the lumbar spine. After 8 weeks of failed conservative management with radiculopathy, surgical decompression via ACDF is indicated.
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A 50-year-old male with cervical spondylosis notices that neck flexion produces an electric shock-like sensation radiating down his spine and into all four limbs. This symptom is called:
Correct. Lhermitte's sign is an electric shock down the spine into the limbs on neck flexion — indicating posterior column or cord dysfunction. It is an important clinical sign of cervical cord compromise.
Lhermitte's sign (phenomenon) is an electric shock-like sensation radiating down the spine and limbs on neck flexion. It indicates posterior column (dorsal column) or cord dysfunction at the cervical level — characteristic of cervical myelopathy, multiple sclerosis, or radiation myelopathy. In the context of spondylosis, it suggests significant cord compression.
Hoffman's sign = flicking the middle finger nail causes involuntary flexion of the thumb/index finger (UMN sign). Spurling's = foraminal compression test for radiculopathy. Romberg's = proprioception test (standing imbalance with eyes closed). Lhermitte's = electrical spinal shock on neck flexion.
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A 62-year-old woman is diagnosed with lumbar spondylosis with symptomatic L3–L4 and L4–L5 disc degeneration. She has chronic low back pain but NO radiculopathy, NO neurological deficit, and NO red flags. Conservative management over 4 months includes physiotherapy, analgesics, and lifestyle modification. Her pain remains 7/10 on VAS. Which intervention is most appropriate at this stage?
Correct. After failed conventional conservative management (physiotherapy, analgesics), the next step for refractory lumbar spondylosis pain WITHOUT neurological compromise is minimally invasive pain intervention — epidural steroid injection or facet joint injection — before considering any surgical option.
For chronic low back pain from lumbar spondylosis without radiculopathy or neurological deficit, an escalating conservative approach is followed: NSAIDs → physiotherapy → epidural steroids/nerve blocks → surgical fusion (last resort for refractory mechanical pain with proven instability). After 4 months of failed physiotherapy and analgesics, a therapeutic lumbar epidural steroid injection or facet joint injection is the appropriate next step before considering surgery.
The management ladder for lumbar spondylosis (no neurological deficit): analgesics → physiotherapy/core strengthening → pain interventions (epidural/facet injections) → surgery (fusion as last resort for instability/refractory). After 4 months failure, interventional pain management precedes surgery.
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