Principal Gray’s Anatomy Review
Due to the technical work on the site downloading books (as well as file conversion and sending books to email/kindle) may be unstable from May, 27 to May, 28 Also, for users who have an active donation now, we will extend the donation period.

Gray’s Anatomy Review

, , ,

Now in its second edition, Gray’s Anatomy Review continues to be an easy-to-use resource that helps you relate anatomy to clinical practice and pass your exams. Designed as a companion to Gray’s Anatomy for Students, this medical textbook is your indispensable resource for both in-course examinations and the USMLE Step 1.

  • Enhance your understanding of the subject and access more detailed information with specific page references to Gray’s Anatomy for Students, plus key answers and explanations to Gray’s Basic Anatomy and Gray’s Atlas of Anatomy.
  • Search the full contents online at Student Consult.
  • Challenge your grasp of anatomical knowledge and the anatomical basis of disease with more than 500 high-quality, USMLE-style questions, complete with answers and rationales, that mirror the actual USMLE Step 1.
  • Visualize key concepts with updated radiologic images and extensive use of photographs.
  • Understand the latest imaging techniques as seen in clinical practice with the most current knowledge available on today’s anatomical imaging modalities.
Año:
2015
Edición:
2
Editorial:
Churchill Livingstone
Idioma:
english
Páginas:
512 / 513
ISBN 10:
0323277888
ISBN 13:
9780323277884
File:
PDF, 70.96 MB
Descarga (pdf, 70.96 MB)

You may be interested in Powered by Rec2Me

 

Most frequently terms

 
 
You can write a book review and share your experiences. Other readers will always be interested in your opinion of the books you've read. Whether you've loved the book or not, if you give your honest and detailed thoughts then people will find new books that are right for them.
1

Bewusstsein / Consciousness

Year:
2016
Language:
german
File:
PDF, 3.04 MB
2

Park’s The Pediatric Cardiology Handbook

Year:
2015
Language:
english
File:
PDF, 5.70 MB
Any screen.
Any time.
Anywhere.
Activate the eBook version
of this title at no additional charge.

Student Consult eBooks give you the power to browse and find content,
view enhanced images, share notes and highlights—both online and offline.

Unlock your eBook today.
1 Visit studentconsult.inkling.com/redeem
2 S
 cratch off your code

Scan this QR code to redeem your
eBook through your mobile device:

3 Type code into “Enter Code” box
4 C
 lick “Redeem”
5 L
 og in or Sign Up
6 G
 o to “My Library”

It’s that easy!

For technical assistance:
email studentconsult.help@elsevier.com
call 1-800-401-9962 (inside the US)
call +1-314-447-8200 (outside the US)
Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on studentconsult.inkling.com.
Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at studentconsult.inkling.com and may not be
transferred to another party by resale, lending or other means.

GRAY’S
ANATOMY
REVIEW

This page intentionally left blank

GRAY’S

ANATOMY
REVIEW

Marios Loukas, MD, PhD
Professor, Department of Anatomical Sciences
Dean of Basic Sciences
St. George’s University School of Medicine
Grenada, West Indies

R. Shane Tubbs, MS, PA-C, PhD
Professor of Anatomy
Children’s of Alabama
Birmingham, Alabama;
Department of Anatomical Sciences
St. George’s University
Grenada, West Indies;
Centre of Anatomy and Human Identification
University of Dundee
Dundee, United Kingdom

SECOND
EDITION

Peter H. Abrahams, MBBS,
FRCS(ED), FRCR, DO(Hon), FHEA
Professor Emeritus of Clinical Anatomy
Institute of Clinical Education
Warwick Medical School
University of Warwick
Coventry, United Kingdom

Stephen W. Carmichael, PhD, DSc
Professor Emeritus of Anatomy and Orthopedic
Surgery
Mayo Clinic
Rochester, Minnesota

1600 John F. Kennedy Blvd.
Ste. 1800
Philadelphia, PA 19103-2899

GRAY’S ANATOMY REVIEW, SECOND EDITION

ISBN: 978-0-323-27788-4

; Copyright  2016 by Elsevier, Inc. All rights reserved.
First edition copyright 2010, Churchill Livingstone, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details on how to seek permission and
further information about the Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be
found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
International Standard Book Number: 978-0-323-27788-4

VP Global Medical Education Content: Madelene Hyde
Senior Content Strategist: Jeremy Bowes
Content Development Specialist: Lauren Boyle
Publishing Services Manager: Patricia Tannian
Senior Project Manager: John Casey
Design Direction: Julia Dummitt

Printed in Canada
Last digit is the print number:

9 8

7

6

5 4 3

2

1

To my daughter, Nicole, my son, Chris, and my wife,
Joanna, for their continuous support and love
ML
To Kevin, Kendall, and Logan Tubbs—
the perfect family
RST
To “Lucy in the Sky with Diamonds,” who puts
up with my early mornings and late nights—
For all the descendants of “Papi and Lulu”
PA
To Susan Stoddard and Allen Carmichael
SC

v

This page intentionally left blank

PREFACE
Rote memorization of anatomic facts has been the
cardinal feature of exhaustive, and exhausting, courses
in human anatomy for many generations of students
in medicine, dentistry, and other allied health science
programs. Often, little distinction was made between
the wheat and the chaff, and little attention was given
to the practical, clinical application of the data. In
the face of the modern explosion of information and
technical advances in the medical sciences, Gray’s
Anatomy for Students was conceived and written as a
clinically oriented, student-friendly textbook of human
anatomy. The authors, Richard L. Drake, A. Wayne
Vogl, and Adam W. M. Mitchell, have provided a
sound basis for student learning and understanding of
both normal and altered human anatomy in the clinical setting.
Gray’s Anatomy Review was designed for use by
students after they have read the textbook and is in
keeping with the objectives of a course that uses this
textbook. The questions, answers, and explanations in
this book are intended to serve multiple purposes for
students in various programs.
1. This review provides a thought-provoking source for
study by students in preparation for examinations in
various programs of gross anatomy.
2. To avoid pointless memorization by the student, all
the questions are framed within clinical vignettes
that guide the student toward practical applications
of the textual material.
3. The multiple-choice, single-best-answer format of
the questions is designed to facilitate student review
in preparation for the USMLE and similar qualifying
examinations.

4. The explanations of the answers emphasize the critical importance of understanding normal and dysfunctional human anatomy.
5. Student understanding is further enhanced by critical examination of alternative, incorrect answers
that students might be tempted to choose.
6. Finally, the review provides a succinct distillation of
the plethora of facts in clinical anatomy, assisting
the student’s learning and understanding of important concepts in the practice of medicine, irrespective of the student’s career choice.
The questions in this review are correlated with the
following textbooks:
• Gray’s Anatomy for Students, ed 3, by Richard L.
Drake, A. Wayne Vogl, and Adam W. M. Mitchell
• Netter Atlas of Human Anatomy, ed 6, by Frank
Netter
• McMinn’s and Abrahams’ Clinical Atlas of Human
Anatomy, ed 7, by Peter H. Abrahams, Jonathan D.
Spratt, Marios Loukas, and Albert N. Van Schoor
Each answer is referenced to pages in Gray’s (GAS),
Netter’s (N) and McMinn’s (McM).
For the embryology chapter we have correlated the
clinical vignettes with Before We Are Born: Essentials
of Embryology and Birth Defects, ed 8, by Keith L
Moore, TVN Persaud, and Mark G. Torchia.
We have incorporated or adapted many drawings,
full-color illustrations, and radiographic images in an
attempt to accelerate the learning process and to
enhance understanding of both the anatomy and the
clinical applications. The primary sources on which we
have drawn for illustrative material are from McMinn’s
and Abrahams’ Clinical Atlas of Human Anatomy.

vii

This page intentionally left blank

ACKNOWLEDGMENTS
A clinical review book is the work not only of the
authors but also of numerous scientific and clinical
friends and colleagues who have been so generous with
their knowledge and given significant feedback and
help. This book would not have been possible were it
not for the contributions of the colleagues and friends
listed below.
A very special group of medical students, members
of the Student Clinical Research Society at the Department of Anatomical Sciences at St. George’s University,
helped enormously with the completion of this project
through their comments and criticism of each chapter
as part of the advisory board of this book.
Advisory Board
Nkosi Alvarez (Neck)
Meha Bhargava (Pelvis and Perineum)
Liann Chin Casey (Lower Limb)
Rana Chakrabarti (Upper Limb)
Ramya Chitters (Embryology)
Monica Dandapani (Abdomen)
Piyumika De Silva (Upper Limb)
Uta Guo (Embryology)
Rich Hajjar (Abdomen)
Roland Howard (Lower Limb)
Lijo C. Illipparambi (Upper Limb)
Theofannis Kollias (Upper Limb)
Jun Lee (Back)
Olivia Lu (Lower Limb)
Prateek Mathur (Head)
Spiro Mavromatis (Neck)
Lewis Musoke (Lower Limb)
Anastasiya Nelyubina (Pelvis and Perineum)
Georgia Paul (Pelvis and Perineum)
Tony Sadek (Thorax)
Shanojan Thiyagalingam (Back)
David Thornton (Abdomen)
Randy Tigue (Head)
Ryan Uyan (Thorax)
Lindsey Van Brunt (Head and Neck)
Danielle Van Patten (Head and Neck)
The following professors from the Department of
Anatomical Sciences at St. George’s University have

also been very helpful with their comments and criticism as part of the advisory board:
Emanuel Baidoo, MD
Feisal Brahim, PhD
Kathleen Bubb, MD
Danny Burns, MD, PhD
James Coey, MBBS
Maira Du Plessis, MSc
Francis Fakoya, MD, PhD
Deon Forrester, MD
Iketchi Gbenimacho, MD
Rachael George, MD
Robert Hage, MD, PhD
Robert Jordan, PhD
Ahmed Mahgoud, MD
Ewarld Marshall, MD
Vid Persaud, MD, PhD
Kazzara Raeburn, MD
Ramesh Rao, MD
Vish Rao, PhD
Deepak Sharma, MD
Alena Wade, MD
Dr. Anthony D’Antoni, PhD, Clinical Professor and
Director of Anatomy at The City College of New York
(CUNY), has always been a great friend and colleague.
His continuous support, comments, criticism, and
enthusiasm have contributed enormously to the completion of this project.
We are especially thankful to Ms. Madelene Hyde,
publisher at Elsevier, for her invaluable insights, advice,
and encouragement.
The authors would also like to thank Jeremy Bowes
and Lauren Boyle, our developmental editor, and all the
team at Elsevier for guiding us through the preparation
of this book.
The authors thank the following individuals and
their institutions for kindly supplying various clinical,
operative, endoscopic, and imaging photographs:
Dr. Ray Armstrong, Rheumatologist, Southampton
General Hospital, Southampton, and Arthritis
ix
Research Campaign

Acknowledgments
Professor Paul Boulos, Surgeon, Institute of Surgical
Studies, University College London Medical School,
London
Professor Norman Browse, Emeritus Professor of
Surgery, and Hodder Arnold Publishers, for permission to use illustrations from Symptoms and Signs
of Surgical Disease, 4th edition, 2005.
Mr. John Craven, formerly Consultant Surgeon, York
District Hospital, York
Professor Michael Hobsley, formerly Head of the
Department of Surgical Studies, The Middlesex Hospital Medical School, London
Mr. Ralph Hutchings, photographer for Imagingbody
.com
Mr. Umraz Khan, Plastic Surgeon, Charing Cross Hospital, London

x

Professor John Lumley, Director, Vascular Surgery Unit,
St. Bartholomew’s and Great Ormond Street Hospitals, London
Dr. J. Spratt, Consultant Radiologist, University Hospital of North Durham
Dr. William Torreggiani, Radiologist, The Adelaide and
Meath Hospital, Tallaght, Dublin
Miss Gilli Vafidis, Ophthalmologist, Central Middlesex
Hospital, London
Mr. Theo Welch, Surgeon, Fellow Commoner Queens’
College, Cambridge
Professor Jamie Weir, Department of Clinical Radiology,
Grampian University Hospitals Trust, Aberdeen,
Scotland, and editor of Imaging Atlas of Human
Anatomy, 3rd edition, Elsevier, 2003.

CONTENTS
1

BACK

5

LOWER LIMB

2

THORAX

6

UPPER LIMB

3

ABDOMEN

7

HEAD AND NECK

4

PELVIS AND PERINEUM

8

EMBRYOLOGY

Questions, 1
Answers, 20

Questions, 39
Answers, 67

Questions, 103
Answers, 139

Questions, 191
Answers, 206

Questions, 233
Answers, 258

Questions, 287
Answers, 319

Questions, 355
Answers, 401

Questions, 459
Answers, 467

Bonus Online-Only Content—To see a list of objectives for each question in the book, activate
your title on www.StudentConsult.Inkling.com using the pin code on the inside front cover

xi

This page intentionally left blank

1
BACK
INTRODUCTION
First Order Question
1 A 35-year-old man is admitted to the emergency
department after a severe car crash. After examining
the patient the emergency medicine physician concludes that the serratus anterior muscle is damaged.
Which of the following nerves innervates the serratus
anterior muscle?
A. Long thoracic
B. Axillary
C. Spinal accessory
D. Dorsal scapular
E. Thoracodorsal
Explanation
A: The long thoracic is the only nerve that innervates
the serratus anterior. The axillary nerve innervates the
deltoid, the spinal accessory nerve innervates the sternocleidomastoid and trapezius, the dorsal scapular
nerve supplies the rhomboid muscles and levator scapulae, and the latissimus dorsi is the muscle supplied by
the thoracodorsal nerve.

First Order Question
2 A 35-year-old man is admitted to the emergency
department after a severe car crash. After examining

the patient the emergency medicine physician concludes that the serratus anterior muscle is damaged.
Which of the following functions does the serratus
anterior muscle serve?
A. Adducts scapula
B. Depresses ribs
C. Protraction and rotation of scapula
D. Elevation of scapula
E. Adducts, extends, and medially rotates arm
Explanation
C: The functions of the serratus anterior are protraction
and rotation of the scapula. The rhomboid major and
minor adduct the scapula, the serratus posterior inferior depresses the lower ribs, the levator scapulae elevates the scapula, and the latissimus dorsi adducts,
extends, and medially rotates the arm.

Second Order Question
3 A 35-year-old man is admitted to the emergency
department after a severe car crash. After examining
the patient the emergency medicine physician concludes that the serratus anterior muscle is damaged.
Which of the following functions will the patient most
likely be unable to perform?
A. Retraction of the scapula
B. Elevation of the scapula
C. Depression of the scapula
1

Back
D. Protraction of the scapula
E. Medial rotation of the scapula
Explanation
D: The serratus anterior muscle pulls the scapula
forward (protraction) over the thoracic wall. Elevation
of the scapula is carried out mainly by the trapezius
and levator scapulae muscles while depression is performed primarily by the lower fibers of the trapezius.
Different muscles contribute to the movement of the
scapula such as the serratus anterior, trapezius, levator
scapulae, rhomboids, and pectoralis minor.

Second Order Question
4 A 35-year-old man is admitted to the emergency
department after a severe car crash. During physical
examination of the patient the emergency medicine
physician observes a winged scapula. Which of the
following muscles is most likely injured?
A. Levator scapulae
B. Serratus anterior
C. Trapezes
D. Rhomboid major and minor
E. Serratus posterior superior
Explanation
B: The serratus anterior muscle pulls the scapula
forward (protraction) and keeps the costal surface of
the scapula closely opposed to the thoracic wall, preventing “winging” of the scapula. The levator scapulae
elevates the scapula. The trapezius muscle is a powerful elevator of the shoulder and also rotates the scapula
during reaching overhead. The rhomboid major and
minor elevate and retract the scapula.

muscles. The deltoid abducts, flexes, and extends while
the teres minor laterally rotates the arm. The spinal
accessory nerve is responsible for supplying the trapezius and sternocleidomastoid muscles. The trapezius
elevates and upwardly rotates the scapula while the
sternocleidomastoid flexes and pulls the chin upward
to the opposite side. The dorsal scapular nerve supplies
the rhomboid major and minor muscles and are responsible for retraction of the scapula. The thoracodorsal
nerve supplies the latissimus dorsi muscle, which
adducts, medially rotates, and extends the arm.

Third Order Question
6 A 35-year-old man is admitted to the emergency
department after a severe car crash. The emergency
medicine physician examines the patient and observes
what is shown in Figure 1-1. Which of the following
nerves is most likely injured?
A. Long thoracic
B. Axillary
C. Spinal accessory
D. Dorsal
E. Thoracodorsal
Explanation
A: The long thoracic nerve innervates the serratus anterior muscle, which protracts the scapula, holds the

Second Order Question
5 A 35-year-old man is admitted to the emergency
department after a severe car crash. While performing
the physical examination the emergency medicine physician observes a winged scapula. Which of the following nerves is most likely injured?
A. Long thoracic
B. Axillary
C. Spinal accessory
D. Dorsal
E. Thoracodorsal
Explanation
A: The long thoracic nerve innervates the serratus anterior muscle, which protracts and upwardly rotates the
scapula. Persons with injury to this nerve will have
their scapulae protrude on their back like a wing. The
2 axillary nerve supplies the deltoid and teres minor

Fig. 1-1

Back
scapula close to the thoracic wall preventing it from
“winging”, and abducts and upwardly rotates the
scapula. Patients with injury to this nerve will have
their scapulae protruding on their back like a wing. The
axillary nerve supplies the deltoid and teres minor
muscles. The deltoid abducts, flexes, and extends and
the teres minor laterally rotates the arm. The spinal
accessory nerve is responsible for supplying the trapezius and sternocleidomastoid muscles. The trapezius
elevates and upwardly rotates the scapula while the
sternocleidomastoid flexes and pulls the chin upward
to the opposite side. The dorsal scapular nerve supplies
the rhomboid major and minor muscles and are responsible for retraction of the scapula. The thoracodorsal
nerve supplies the latissimus dorsi muscle, which
adducts, medially rotates, and extends the arm.

Fourth Order Question
7 A 35-year-old man is admitted to the emergency
department after a severe car crash. The emergency
medicine physician examines the patient and observes
what is shown in Figure 1-1. Which of the following

functions will the patient most likely be unable to
perform during physical examination?
A. Lateral rotation of the shoulder joint
B. Abduction of the shoulder joint from 0 to 90
degrees
C. Flexion of the shoulder joint
D. Extension of the shoulder joint
E. Abduction of the shoulder joint above 90
degrees
Explanation
E: In this image, the patient has a winged scapula. This
occurs as a result of damage to the long thoracic nerve,
which innervates the serratus anterior muscle. The
functions of this muscle are protraction of the scapula
and superior rotation of the glenoid fossa. The supraspinatus abducts the arm for about the first 12 degrees,
and then the deltoid abducts the arm to about 90
degrees. Elevating the arm further requires rotation of
the scapula (including superior rotation of the glenoid
fossa) that is normally done by the serratus anterior.

3

Back

MAIN QUESTIONS
1 A 55-year-old man with severe coughing is
admitted to the hospital. Radiologic examination is
consistent with tuberculosis of the right lung, with
extension to the thoracic vertebral bodies of T6 and T7,
producing a “gibbus deformity.” Which of the following
conditions is most likely also to be confirmed by radiologic examination?
A. Hyperlordosis
B. Hyperkyphosis
C. Scoliosis
D. Spina bifida
E. Osteoarthritis
2 A 68-year-old man is admitted to the hospital due
to severe back pain. Radiologic examination reveals
severe osteoporosis of the vertebral column, with compression fractures to vertebrae L4 and L5. Which of the
following parts of the vertebrae are most likely to be
fractured in this patient?
A. Spinous process
B. Vertebral bodies
C. Transverse process
D. Superior articular process
E. Intervertebral disc
3 A 45-year-old man is admitted to the hospital
because of severe pain in the back and lower limb.
Radiologic examination reveals spinal canal stenosis
syndrome. Which of the following conditions is most
likely to be confirmed by a magnetic resonance imaging
(MRI) examination?
A. Hypertrophy of supraspinous ligament
B. Hypertrophy of interspinous ligament
C. Hypertrophy of ligamentum flavum
D. Hypertrophy of anterior longitudinal ligament
E. Hypertrophy of nuchal ligament
4 A 35-year-old man is admitted to the hospital after
a severe car crash. Radiologic examination reveals an
injury to the dorsal surface of the neck and a fracture
of the medial border of the right scapula. During physical examination, the patient presents with the scapula
retracted laterally on the affected side. Which of the
following nerves has most likely been injured on that
side?
A. Axillary
B. Long thoracic
C.
Dorsal scapular
4

D. Greater occipital
E. Suprascapular
5 A 64-year-old man arrived at the clinic with a
painful rash and skin eruptions that are localized
entirely on one side of his body, closely following the
dermatome level of the spinal nerve C7. The patient
was diagnosed with the a herpes zoster virus infection
known as “shingles.” In what structure has the virus
most likely proliferated to cause the patient’s current
condition?
A. The sympathetic chain
B. The dorsal root ganglion of the C7 spinal
nerve
C. The lateral horn of the C7 spinal cord segment
D. The posterior cutaneous branch of the dorsal
primary ramus of C7
E. The ventral horn of the C7 spinal cord
segment
6 A 45-year-old woman states that she has experienced moderate pain for 2 years over her left lower
back; pain that radiates to her left lower limb. She
states that after lifting a case of soft drinks, the pain
suddenly became intense. She was admitted to the
emergency department. Radiologic examination revealed intervertebral disc herniation between vertebral
levels L4 and L5. Which of the following nerves was
most likely affected by the disc herniation?
A. L1
B. L2
C. L3
D. L4
E. L5
7 A 3-year-old boy is brought by his mother to the
emergency department with severe headache, high
fever, malaise, and confusion. Radiologic and physical
examinations reveal that the patient suffers from meningitis. A lumbar puncture is ordered to confirm the
diagnosis. Which vertebral level is the most appropriate
location for the lumbar puncture?
A. T12 to L1
B. L1 to L2
C. L2 to L3
D. L4 to L5
E. L5 to S1
8 When a lumbar puncture is performed to sample
cerebrospinal fluid, which of the following external
landmarks is the most reliable to determine the position
of the L4 vertebral spine?

Back
A.
B.
C.
D.
E.

The
The
The
The
The

inferior angles of the scapulae
highest points of the iliac crests
lowest pair of ribs bilaterally
sacral hiatus
posterior inferior iliac spines

9 A 39-year-old man presents with severe neck pain
after a whiplash injury, sustained when his car was
struck from behind. Radiologic studies reveal trauma
to the ligament lying on the anterior surface of the
cervical vertebral bodies. Which ligament is most likely
disrupted?
A. Anterior longitudinal ligament
B. Ligamentum flavum
C. Nuchal ligament
D. Posterior longitudinal ligament
E. Transverse cervical ligament
10 A 65-year-old man complains of severe back pain
and the inability to move his left lower limb. Radiologic
studies demonstrate compression of nerve elements at
the intervertebral foramen between vertebrae L5 and
S1. Which structure is most likely responsible for this
space-occupying lesion?
A. Anulus fibrosus
B. Nucleus pulposus
C. Posterior longitudinal ligament
D. Anterior longitudinal ligament
E. Ligamentum flavum
11 A 27-year-old man is admitted to the emergency
department after a car crash. Physical examination
reveals weakness during medial rotation and adduction
of the humerus. Which of the following nerves was
most probably injured?
A. Thoracodorsal
B. Axillary
C. Dorsal scapular
D. Spinal accessory
E. Radial
12 A 39-year-old woman complains of an inability to
reach the top of her head to brush her hair with her
right hand. History reveals that she had undergone a
mastectomy procedure of her right breast 2 months
earlier. Physical examination demonstrates winging
of her right scapula. Which nerves were most likely
damaged during surgery?
A. Axillary
B. Spinal accessory

C. Long thoracic
D. Dorsal scapular
E. Thoracodorsal
13 A 19-year-old man is brought to the emergency
department after dislocating his shoulder while playing
football. Following treatment of the dislocation, he
cannot initiate abduction of his arm. An MRI of the
affected shoulder shows a torn muscle. Which muscle
was most likely damaged by the injury?
A. Coracobrachialis
B. Long head of the triceps brachii
C. Pectoralis minor
D. Supraspinatus
E. Teres major
14 A 1-year-old girl is brought to the clinic for a
routine checkup. The child appears normal except for
a dimpling of the skin in the midline of the lumbar
region with a tuft of hair growing over the dimple.
What is this relatively common condition that results
from incomplete embryologic development?
A. Meningomyelocele
B. Meningocele
C. Spina bifida occulta
D. Spina bifida cystica
E. Rachischisis
15 A young resident complains of an itch on his back
that appears to be caused by an insect bite. Which
nerve fibers carry the sensation of a mosquito bite on
the back, just lateral to the spinous process of the T4
vertebra?
A. Somatic afferent
B. Somatic efferent
C. Visceral afferent
D. Visceral efferent
E. Somatic efferent and visceral afferent
16 A 15-year-old woman was suspected of having
meningitis. To obtain a sample of cerebrospinal fluid
by spinal tap in the lumbar region (lumbar puncture),
the tip of the needle must be placed in which of the
following locations?
A. In the epidural space
B. Between anterior and posterior longitudinal
ligaments
C. Superficial to the ligamentum flavum
D. Between arachnoid mater and dura mater
E. In the subarachnoid space

5

Back
17 A 19-year-old man is diagnosed with a herniated
disc but he has no symptoms of spinal cord injury. In
the event of intervertebral disc herniation in the cervical region, which of the following ligaments is in an
anatomic position to protect the spinal cord from direct
compression?
A. Supraspinous
B. Posterior longitudinal
C. Anterior longitudinal
D. Ligamentum flavum
E. Nuchal ligament
18 In spinal anesthesia, the needle is often inserted
between the spinous processes of the L4 and L5 vertebrae to ensure that the spinal cord is not injured. This
level is safe because in the adult the spinal cord usually
terminates at the disc between which of the following
vertebral levels?
A. T11 and T12
B. T12 and L1
C. L1 and L2
D. L2 and L3
E. L3 and L4
­

19 A 22-year-old woman is diagnosed with Ray
naud’s disease. In such a case, the patient suffers
chronic vasospasm in response to cold. This can lead
to arterial constriction and painful ischemia, especially
in the fingers or toes. Relief from the symptoms in the
hands would require surgical division of which of the
following neural elements?
A. Lower cervical and upper thoracic
sympathetic fibers
B. Lower cervical and upper thoracic ventral
roots
C. Lower cervical and upper thoracic dorsal roots
D. Lower cervical and upper thoracic spinal
nerves
E. Bilateral spinal accessory nerves
20 A 69-year-old woman visits her physician due to
severe neck pain. Radiologic studies reveal bony
growths (osteophytes) in the intervertebral foramen
between vertebrae C2 and C3. Which of the following
muscles would be most likely affected by this
condition?
A. Rhomboideus major
B. Serratus anterior
C. Supraspinatus
D. Diaphragm
6
E. Latissimus dorsi

21 A 42-year-old woman is diagnosed with stenosis
of the cervical vertebral canal. A laminectomy of two
vertebrae is performed. Which of the following ligaments will most likely also be removed?
A. Anterior longitudinal
B. Denticulate
C. Ligamentum flavum
D. Nuchal
E. Cruciate
22 A 28-year-old pregnant woman is admitted to the
obstetrics department for delivery. In the final stages
of labor, a caudal anesthetic is administered via the
sacral hiatus. Into which of the following spaces in the
sacral canal is the anesthetic placed?
A. Vertebral canal
B. Vertebral venous plexus
C. Epidural space
D. Subarachnoid space
E. Subdural space
23 A 12-year-old child was brought to the emergency
department by his parents because he has been suffering from a very high fever and severe stiffness in his
back. The initial diagnosis is meningitis. The attending
physician orders a lumbar puncture to confirm the
diagnosis. Upon microscopic examination of the cerebrospinal fluid, hematopoietic cells are seen. Which of
the following ligaments was most likely penetrated by
the needle?
A. Supraspinous
B. Denticulate
C. Anterior longitudinal
D. Posterior longitudinal
E. Nuchal ligament
24 A 25-year-old male racing car driver is admitted
to the emergency department after a severe car crash.
Radiologic studies reveal damage to the tip of the transverse process of the third cervical vertebra, with a
significantly large pulsating hematoma. What artery is
the most likely to have been damaged?
A. Anterior spinal artery
B. Vertebral artery
C. Ascending cervical artery
D. Deep cervical artery
E. Posterior spinal arteries
25 A 79-year-old man, a retired military veteran,
presents to the outpatient clinic with an abnormal curvature of the vertebral column. He complains that it

Back
has become increasingly painful to walk around town.
Upon physical examination, he has an abnormally
increased convexity to his thoracic curvature resulting
from osteoporosis. Which of the following is the most
likely clinical condition of this patient’s spine?
A. Scoliosis
B. Hyperkyphosis
C. Spinal stenosis
D. Lordosis
E. Herniated disc
26 A 42-year-old woman complains of pain and stiffness in her neck. She was injured sliding into second
base headfirst during her company’s softball game.
Radiographs reveal no fractures of her spine. However,
upon physical examination, her right shoulder is drooping and she has difficulty in elevating that shoulder. If
you ordered an MRI, it would most likely reveal soft
tissue damage involving which of the following nerves?
A. Thoracodorsal nerve
B. Spinal accessory nerve
C. Dorsal scapular nerve
D. Greater occipital nerve
E. Axillary nerve
27 A 53-year-old man was in a head-on vehicle collision that resulted in compression of his spinal cord
by the dens (odontoid process) of the axis, with resulting quadriplegia. Which of the following ligaments was
most probably torn?
A. Anterior longitudinal ligament
B. Transverse ligament of the atlas
C. Ligamentum flavum
D. Supraspinous ligament
E. Nuchal ligament
28 An 18-year-old woman passenger injured in a
rollover car crash was rushed to the emergency department. After the patient is stabilized, she undergoes
physical examination. She demonstrates considerable
weakness in her ability to flex her neck, associated with
injury to CN XI. Which of the following muscles is most
probably affected by nerve trauma?
A. Iliocostalis thoracis
B. Sternocleidomastoid
C. Rhomboid major
D. Rhomboid minor
E. Teres major
29 A 23-year-old man was killed in a high-speed
motor vehicle collision after racing his friend on a local

highway. When the medical examiner arrives at the
scene, it is determined that the most likely cause of
death was a spinal cord injury. Upon confirmation by
autopsy, the medical examiner officially reports that the
patient’s cause of death was a fracture of the pedicles
of the axis (C2). Breaking of which of the following
ligaments would be most likely implicated in this fatal
injury?
A. Ligamentum flavum
B. Nuchal ligament
C. Cruciform ligament
D. Posterior longitudinal ligament
E. Supraspinous ligament
30 A 65-year-old man is injured when a vehicle traveling at a high rate of speed hits his car from behind.
Radiologic examination reveals that two of his articular
processes are now locked together, a condition known
as “jumped facets.” In which region of the spine is this
injury most likely to occur?
A. Cervical
B. Thoracic
C. Lumbar
D. Lumbosacral
E. Sacral
31 Following a car crash, a 47-year-old woman
complains of severe headache and back pain. Radiologic examination reveals bleeding of the internal vertebral venous plexus (of Batson), resulting in a large
hematoma. In what space has the blood most likely
accumulated?
A. Subarachnoid space
B. Subdural space
C. Central canal
D. Epidural space
E. Lumbar cistern
32 A 32-year-old man, an elite athlete, was lifting
heavy weights during an intense training session. The
athlete felt severe pain radiating to the posterior aspect
of his right thigh and leg. The patient was taken to the
hospital where MRI revealed a ruptured L4/L5 intervertebral disc. Which nerve is most probably affected?
A. L3
B. L4
C. L2
D. L5
E. S1

7

Back
33 A 24-year-old patient suffered a lower back strain
after a severe fall while skiing. MRI studies reveal
injury to the muscles responsible for extending and
laterally bending the trunk. What arteries provide blood
supply for these muscles?
A. Subscapular
B. Thoracodorsal
C. Anterior intercostal
D. Suprascapular
E. Posterior intercostal

lesion between the trapezius and latissimus dorsi
muscles on the right lateral side of his back. Upon
admission to the hospital, physical examination reveals
weak adduction and medial rotation of his arm. Which
of the following muscles is most probably injured?
A. Teres minor
B. Triceps brachii
C. Supraspinatus
D. Infraspinatus
E. Teres major

34 A 22-year-old male soccer player is forced to
leave the game following a head-to-head collision with
another player. He is admitted to the hospital, and
radiologic examination reveals slight dislocation of the
atlantoaxial joint. As a result, he experiences decreased
range of motion at that joint. What movement of the
head would most likely be severely affected?
A. Rotation
B. Flexion
C. Abduction
D. Extension
E. Adduction

38 A 22-year-old man is thrown through a plate glass
wall in a fight. Radiologic examination reveals that the
lateral border of his right scapula is shattered. He is
admitted to the emergency department, and physical
examination reveals difficulty laterally rotating his arm.
Which of the following muscles is most probably
injured?
A. Teres major
B. Infraspinatus
C. Latissimus dorsi
D. Trapezius
E. Supraspinatus

35 A 42-year-old man is struck in the back, rupturing
the internal vertebral venous plexus (of Batson). Radiologic studies reveal a hematoma causing compression
of the spinal cord. When aspirating the excess blood,
the physician performing the procedure should stop the
needle just before puncturing which of the following
structures?
A. Spinal cord
B. Pia mater
C. Arachnoid mater
D. Dura mater
E. Ligamentum flavum

39 A 24-year-old woman presents with severe headache, photophobia, and stiffness of her back. Physical
examination reveals positive signs for meningitis. The
attending physician decides to perform a lumbar puncture to determine if a pathogen is in the cerebrospinal
fluid (CSF). What is the last structure the needle will
penetrate before reaching the lumbar cistern?
A. Arachnoid mater
B. Dura mater
C. Pia mater
D. Ligamentum flavum
E. Posterior longitudinal ligament

36 A 35-year-old man pedestrian is crossing a busy
intersection and is hit by a truck. He is admitted to the
emergency department, and a CT scan reveals a dislocation of the fourth thoracic vertebra. Which of the
following costal structures is most likely also involved
in the injury?
A. Head of the fourth rib
B. Neck of the fourth rib
C. Head of the third rib
D. Tubercle of the third rib
E. Head of the fifth rib

40 A 19-year-old presents at the emergency department with high fever, severe headache, nausea, and
stiff neck that have persisted for 3 days. The attending
physician suspects meningitis and obtains a sample of
CSF using a lumbar puncture. From which of the following spaces was the CSF collected?
A. Epidural space
B. Subdural space
C. Subarachnoid space
D. Pretracheal space
E. Central canal of the spinal cord

37 A 20-year-old male hiker suffers a deep puncture

41 A 38-year-old man is admitted to the emergency
department after a car collision. During physical

8 wound during a fall. Physical examination reveals a

Back
examination several lacerations to the back are discovered. Pain from lacerations or irritations of the skin of
the back is conveyed to the central nervous system by
which of the following?
A. Dorsal primary rami
B. Communicating rami
C. Ventral primary rami
D. Ventral roots
E. Intercostal nerves
42 A 66-year-old woman had been diagnosed with a
tumor on her spine. She has started to retain urine and
is experiencing rectal incontinence. Both of these symptoms are signs of conus medullaris syndrome. At which
of the following vertebral levels is the tumor probably
located?
A. L3/L4
B. L3
C. L4
D. T12 to L2
E. T11
43 Examination of a 3-day-old male infant reveals
protrusion of his spinal cord and meninges from a
defect in the lower back. Which of the following
describes this congenital anomaly?
A. Avulsion of meninges
B. Meningitis
C. Spina bifida occulta
D. Spina bifida with myelomeningocele
E. Spina bifida with meningocele
44 A 32-year-old mother complains of serious pain
in the coccygeal area some days after giving birth. To
determine whether the coccyx is involved, a local anesthetic is first injected in the region of the coccyx and
then dynamic MRI studies are performed. Physical
examination reveals pain with palpation to the region
of the coccyx. The local anesthetic is used to interrupt
which of the following nerve pathways?
A. Visceral afferents
B. Somatic efferent
C. Somatic afferent
D. Sympathetic preganglionic
E. Parasympathetic preganglionic
45 During a routine physical examination, a 65-yearold man is tested for ease and flexibility of the movements of his lumbar region. Which of the following
movements is most characteristic of the intervertebral
joints in the lumbar region?

A.
B.
C.
D.
E.

Circumduction
Lateral flexion
Abduction
Adduction
Inversion

46 A 72-year-old man with cancer of the prostate
gland presents with loss of consciousness and seizures.
A CT scan is performed and a brain tumor is diagnosed.
The tumor spread to the brain from the pelvis via the
internal vertebral venous plexus (of Batson). What
feature of the plexus allows this to happen?
A. The internal venous plexus contains the
longest veins in the body.
B. The internal venous plexus has valves that
ensure one-way movement of blood.
C. The internal venous plexus is located in the
subarachnoid space.
D. The internal venous plexus is, in general,
valveless.
E. The internal venous plexus is located in the
subdural space.
47 A 26-year-old man painting his house slipped and
fell from the ladder, landing on the pavement below.
After initial examination in the emergency department,
the patient is sent to the radiology department. Radiographs reveal that the portion of his left scapula that
forms the tip, or point, of the shoulder has been fractured. Which part of the bone was fractured?
A. Coracoid process
B. Superior angle of the scapula
C. Glenoid
D. Spine of the scapula
E. Acromion
48 A 43-year-old male construction worker survived
a fall from a two-story building but lost all sensation
in his lower limbs and was admitted to the hospital for
examination and treatment. Radiologic studies revealed
that he crushed his spinal cord at vertebral level C6.
Which of the following muscles will most likely be
paralyzed?
A. Sternocleidomastoid
B. Trapezius
C. Diaphragm
D. Latissimus dorsi
E. Deltoid
49 A maternal serum sample with high alphafetoprotein alerted the obstetrician to a possible neural 9

Back
tube defect. Ultrasound diagnosis revealed a myelomeningocele protruding from the back of the child. Which
of the following is the most likely diagnosis of this
congenital anomaly?
A. Cranium bifida
B. Spina bifida occulta
C. Spina bifida cystica
D. Hemothorax
E. Caudal regression syndrome
50 A 7-year-old girl who is somewhat obese is
brought to the emergency department because of a soft
lump above the buttocks. Upon physical examination
you note the lump is located just superior to the iliac
crest unilaterally on the left side. The protrusion is deep
to the skin and pliable to the touch. Which of the following is the most probable diagnosis?
A. Tumor of the external abdominal oblique
muscle
B. Herniation at the lumbar triangle (of Petit)
C. Indirect inguinal hernia
D. Direct inguinal hernia
E. Femoral hernia
51 A 54-year-old woman is admitted to the emergency department due to increasing back pain over the
preceding year. MRI reveals that her intervertebral discs
have been compressed. It is common for the discs to
decrease in size in people older than 40, and this can
result in spinal stenosis and disc herniation. At which
locations are the spinal nerves most likely to be
compressed?
A. Between the denticulate ligaments
B. As they pass through the vertebral foramen
C. Between the superior and inferior articular
facets
D. Between inferior and superior vertebral
notches
E. Between the superior and inferior
intercostovertebral joints
52 A 37-year-old pregnant woman is given a caudal
epidural block to alleviate pain during vaginal delivery.
Caudal epidural blocks involve injection of local anesthetic into the sacral canal. Which of the following
landmarks is most commonly used for the caudal epidural block?
A. Anterior sacral foramina
B. Posterior sacral foramina
C. Cornua of the sacral hiatus

10

D. Intervertebral foramina
E. Median sacral crest
53 A 34-year-old pregnant woman in the maternity
ward was experiencing considerable pain during labor.
Her obstetrician decided to perform a caudal epidural
block. What are the most important bony landmarks
used for the administration of such anesthesia?
A. Ischial tuberosities
B. Ischial spines
C. Posterior superior iliac spines
D. Sacral cornua
E. Coccyx
54 A 22-year-old man is brought into the emergency
department following a brawl in a tavern. He has severe
pain radiating across his back and down his left upper
limb. He supports his left upper limb with his right
hand, holding it close to his body. Any attempt to move
the left upper limb greatly increases the pain. A radiograph is ordered and reveals an unusual sagittal fracture through the spine of the left scapula. The fracture
extends superiorly toward the suprascapular notch.
Which nerve is most likely affected?
A. Suprascapular nerve
B. Thoracodorsal nerve
C. Axillary nerve
D. Subscapular nerve
E. Suprascapular nerve and thoracodorsal nerve
55 A 5-year-old boy is admitted to the hospital
because of pain in the upper back. Radiologic examination reveals abnormal fusion of the C5 and C6 vertebrae
and a high-riding scapula. Which of the following is
the most likely diagnosis?
A. Lordosis
B. Kyphosis
C. Scoliosis
D. Spina bifida
E. Klippel-Feil syndrome
56 A 53-year-old man is admitted to the emergency
department due to severe back pain. MRI examination
reveals anterior dislocation of the body of the L5 vertebra upon the sacrum. Which of the following is the
most likely diagnosis?
A. Spondylolysis
B. Spondylolisthesis
C. Herniation of intervertebral disc
D. Lordosis
E. Scoliosis

Back
57 A male newborn infant is brought to the clinic by
his mother and diagnosed with a congenital malformation. MRI studies reveal that the cerebellum and
medulla oblongata are protruding inferiorly through the
foramen magnum into the vertebral canal. What is this
clinical condition called?
A. Meningocele
B. Klippel-Feil syndrome
C. Chiari II malformation
D. Hydrocephalus
E. Tethered cord syndrome
58 A 62-year-old woman is admitted to the hospital
because of her severe back pain. Radiologic examination reveals that the L4 vertebral body has slipped
anteriorly, with fracture of the zygapophysial joint
(Fig. 1-2). What is the proper name of this condition?
A. Spondylolysis and spondylolisthesis
B. Spondylolisthesis
C. Crush vertebral fracture
D. Intervertebral disc herniation
E. Klippel-Feil syndrome
59 A 40-year-old woman survived a car crash in
which her neck was hyperextended when her vehicle
was struck from behind. At the emergency department,
a plain radiograph of her cervical spine revealed a
fracture of the odontoid process (dens). Which of the
following was also most likely injured?

L

Fig. 1-2

A.
B.
C.
D.
E.

Anterior arch of the atlas
Posterior tubercle of the atlas
Atlanto-occipital joint
Inferior articular process of the axis
Anterior tubercle of the atlas

60 A 34-year-old woman is admitted to the emergency department after a car crash. Radiologic examination reveals a whiplash injury in addition to
hyperextension of her cervical spine. Which of the following ligaments will most likely be injured?
A. Ligamentum flavum
B. Anterior longitudinal ligament
C. Posterior longitudinal ligament
D. Anulus fibrosus
E. Interspinous ligament
61 A 23-year-old college student is admitted to the
emergency department after jumping from a 50-foot
high waterfall. The MRI of his back reveals a lateral
shift of the spinal cord to the left. Which of the following structures has most likely been torn to cause the
deviation?
A. Posterior longitudinal ligament
B. Tentorium cerebelli
C. Denticulate ligaments
D. Ligamentum flavum
E. Nuchal ligament
62 A 6-year-old boy is admitted to the hospital with
coughing and dyspnea. During taking of the history, he
complains that it feels like there is glass in his lungs.
Auscultation reveals abnormal lung sounds. The abnormal lung sounds are heard most clearly during inhalation with the scapulae protracted. Which of the
following form the borders of a triangular space where
one should place the stethoscope in order to best hear
the lung sounds?
A. Latissimus dorsi, trapezius, medial border of
scapula
B. Deltoid, levator scapulae, trapezius
C. Latissimus dorsi, external abdominal oblique,
iliac crest
D. Quadratus lumborum, internal abdominal
oblique, inferior border of the twelfth rib
E. Rectus abdominis, inguinal ligament, inferior
epigastric vessels
63 A 45-year-old woman is admitted to the outpatient clinic for shoulder pain. During physical examination she presents with weakened shoulder movements. 11

Back
A. Injury to the left vertebral artery
B. Injury of the great radicular artery (of
Adamkiewicz)
C. Ligation of the posterior spinal artery
D. Transection of the conal segment of the spinal
cord
E. Division of the thoracic sympathetic chain

Fig. 1-3
Radiologic examination reveals signs of quadrangular
space syndrome, causing weakened shoulder movements. Which of the following nerves is most likely
affected?
A. Suprascapular
B. Subscapular
C. Axillary
D. Radial
E. Ulnar
64 A 29-year-old female elite athlete was lifting
heavy weights during an intense training session. The
athlete felt severe pain radiate suddenly to the posterior
aspect of her right thigh and leg. The patient was taken
to the hospital where an MRI was performed (Fig. 1-3).
Which nerve was most probably affected?
A. L3
B. L4
C. L2
D. L5
E. S1
65 A 58-year-old man in the intensive care ward
exhibited little voluntary control of urinary or fecal
activity following repair of an abdominal aortic aneurysm. In addition, physical examination revealed widespread paralysis of his lower limbs. These functions
were essentially normal prior to admission to the hospital. The most likely cause of this patient’s problems
12 is which of the following?

66 A 23-year-old woman is admitted to the hospital
due to back pain. Radiologic examination reveals that
she suffers from a clinical condition affecting her vertebral column. Her history reveals that she suffered
from polio and has a muscular dystrophy. Which of the
following conditions of the vertebral column will most
likely be present in this patient?
A. Hyperlordosis
B. Hyperkyphosis
C. Scoliosis
D. Spina bifida
E. Osteoarthritis
67 A 26-year-old competitive football player has
been complaining of pain, weakness, numbness, and
tingling for the past 2 months in his upper limb. Imaging
studies reveal a cervical disc herniation compressing
the nerve roots and a portion of the spinal cord. An
anterior cervical discectomy and fusion (ACDF) surgery
is performed. The intervertebral disc is examined upon
removal and the anulus fibrosus and nucleus pulposus
are severely damaged posterolaterally. What type of
cartilage most likely gives the tensile strength of the
intervertebral disc?
A. Hyaline
B. Elastic
C. Fibrous
D. Epiphysial
E. Elastic and fibrous
68 A 26-year-old competitive football player has
been complaining of pain, weakness, numbness, and
tingling for the past 2 months in his upper limb. Imaging
studies reveal a cervical disc herniation compressing
the nerve roots and a portion of the spinal cord. An
ACDF surgery is performed. The intervertebral disc is
examined upon removal and the nucleus and anulus
and nucleus pulposus are severely damaged posterolaterally. What is the embryologic origin of the anulus
fibrosus and nucleus pulposus, respectively?
A. Notochord and neural crest cells
B. Neural crest cells and ectoderm
C. Sclerotome and myotome

Back
D. Mesenchymal cells from sclerotome and
neural crest cells
E. Mesenchymal cells from sclerotome and
notochord
69 A 55-year-old woman has suffered from a middle
ear infection for the past month. She recently developed right-sided miosis, partial ptosis, anhydrosis, and
redness of the conjunctiva. Biopsy examination of
which of the following structures would show the cell
bodies of neurons affected by this disease?
A. Anterior gray horn of the spinal cord
B. Lateral gray horn of the spinal cord
C. Posterior gray horn of the spinal cord
D. Spinal ganglia
E. Lateral column of spinal cord white matter
70 A 62-year-old man is admitted to the emergency
department after a severe car crash resulting in a whiplash injury. MRI examination reveals several hairline
vertebral fractures in the cervical region impinging the
dorsal primary rami of the same levels. Two months
after the injury the patient recovered well, however,
there is still some weakness in the function of a muscle.
Which of the following muscles is most likely affected?
A. Rhomboid major
B. Levator scapulae
C. Rhomboid minor
D. Semispinalis capitis
E. Latissimus dorsi
71 A 22-year-old man has suffered from headaches
and some muscle weakness to his upper muscles of the
back for the last 6 months. An MRI shows a large tumor
compressing the suboccipital and greater occipital
nerves. Which of the following muscles will most likely
still be functioning normally?
A. Rectus capitis posterior major and minor
B. Semispinalis capitis
C. Splenius capitis
D. Obliquus capitis superior
E. Obliquus capitis inferior and lateral
72 A 36-year-old man was found guilty of first-degree
murder and sentenced to death by judicial hanging.
The radiological image below shows the vertebra that
is fractured as a result of the hanging. The mechanism
of injury resulting in death is forcible hyperextension
resulting in a fracture of which of the following
structures?
A. Odontoid process
B. Transverse process

C. Lateral mass
D. Pedicle (pars articularis)
E. Spinous process
73 A 72-year-old woman presented to her primary
care physician after sustaining a fall in her bathroom.
Her vital signs were normal and routine blood work
was obtained for analysis. As part of her work up, a
radiograph of her vertebral column was performed and
revealed a wedge fracture at the fourth thoracic vertebra and thin cortical bone showing signs of osteoporotic changes. What will be the most likely type of
abnormal spinal curvature in such a patient?
A. Hyperkyphosis
B. Scoliosis
C. Hyperlordosis
D. Normal
E. Primary
74 A 65-year-old woman who has been otherwise
well presents to her physician with complaints of a
group of painful blisters over her back in the distribution of the T9 dermatome. She noticed that a few days
prior to the eruption of the blisters she experienced an
intense burning sensation over her skin. She was diagnosed with herpes zoster (shingles). Where are the
neural cell bodies located that are responsible for the
pain sensation?
A. Dorsal horn
B. Lateral horn
C. Dorsal root ganglia
D. Sympathetic chain ganglia
E. White rami communicans
75 A 53-year-old man was in a head-on collision
resulting in the dens crushing the spinal cord. Which
ligament was most likely torn for the dens to crush the
spinal cord?
A. Anterior and posterior longitudinal ligaments
B. Transverse ligament of the atlas
C. Interspinous ligament
D. Supraspinous ligament
E. Nuchal ligament
76 A 16-year-old girl is sent for a presports physical
examination prior to the beginning of her school year.
She has no medical complaints or any clinical past
history. On physical examination, the physician notices
one shoulder is higher than the other. The student is
then asked to bend forward at the waist to touch her
toes. This maneuver results in a posterior bulging of

13

Back
the ribs on the right side. Which one of the following
is most likely diagnosis?
A. Kyphosis
B. Spondylosis
C. Lordosis
D. Spondylolisthesis
E. Scoliosis
77 A 60-year-old man has been feeling sharp pains
over his left lower chest and back for several days. A
rash of red erupted vesicles is seen at the left border
of the sternum just at the level of the xiphoid process.
Antiviral treatment is given for herpes zoster. Which of
the following locations will contain the neural cell
bodies responsible for the painful sensation?
A. Ventral horn of T6 spinal cord segment
B. Lateral horn of T6 spinal cord segment
C. Dorsal root ganglion of T4 spinal nerve
D. Dorsal root ganglion of T6 spinal nerve
E. Dorsal root ganglion of T10 spinal nerve
78 A 70-year-old man with prostate cancer is experiencing sharp shooting pains radiating from his neck
into the upper limb. An MRI of his spine demonstrates
a small metastatic mass in the cervical region extending
into the left intervertebral foramen between C6 and C7.
The intervertebral discs appear normal. Which neural
structure is most likely being compressed by the metastatic mass to account for the pain?
A. C8 spinal nerve
B. Dorsal horn of C6 spinal cord segment
C. C6 spinal nerve
D. Dorsal horn of C7 spinal nerve
E. C7 spinal nerve
79 A 3-day-old girl develops a fever. She is irritable
and not feeding. As part of the workup for fever of
unknown origin, a lumbar puncture is performed. This
puncture must be done below the spinal cord which
usually ends at which vertebral level in a patient of this
age?
A. L1
B. S1
C. L3
D. S3
E. L5
80 During a surgical procedure to debride an abscess
involving the erector spinae muscle at vertebral level
T8, the nerve branch supplying the skin and this muscle
14 is unavoidably severed. What are the anatomical

locations of the cell bodies of the nerve fibers normally
found in this branch?
A. Ventral horn and dorsal horn
B. Ventral horn, dorsal horn, and lateral horn
C. Ventral horn, dorsal root ganglion, and lateral
horn
D. Ventral horn, dorsal root ganglion, and
sympathetic paravertebral ganglion
E. Ventral horn, dorsal horn, and dorsal root
ganglion
81 While waiting in his car at a stop sign, a 28-yearold man was rear-ended by a van, resulting in neck
hyperextension. He was admitted to the emergency
department and a whiplash injury was diagnosed. The
next day his neck was stiff and painful. Which structure
was most likely damaged to cause the pain?
A. Anterior longitudinal ligament
B. Posterior longitudinal ligament
C. Ligamentum flavum
D. Intervertebral disc
E. Supraspinous ligament
82 A 38-year-old man who is a professional golfer
complains of chronic lower back pain with radiating
pain to the heel. The pain is so debilitating that he now
has trouble ambulating. MRI of the lower back reveals
severe narrowing of an intervertebral foramen (IVF),
which has caused compression of the exiting nerve
root. Surgery is required to correct the problem. During
surgery the neurosurgeon carefully accesses the IVF
using a lateral approach and shaves bone off the superior margin (roof) of the IVF to decompress the exiting
nerve root. Which of the following vertebral bony features is the neurosurgeon most likely shaving off?
A. Superior articular process
B. Lamina
C. Inferior articular process
D. Pedicle
E. Spinous process
83 The following statement was found in the radiology report of a magnetic resonance imaging scan of the
cervical spine: “An acute posterolateral herniation of
the most superiorly located intervertebral disc is located
within the corresponding intervertebral foramen and
compressing the exiting nerve.” Which of the following
nerves was the radiologist most likely referring to in
the report?
A. C1
B. C2

Back
C. C3
D. C4
E. C5
84 A 14-year-old girl accidentally flipped her bicycle
off a curb, fell, and landed on her face. Although she
was wearing a helmet, she landed in such a way that
her neck was forced into hyperextension. Which of the
following ligaments of the cervical spine was stretched
to the greatest degree during her injury?
A. Posterior longitudinal ligament
B. Ligamentum nuchae
C. Ligamenta flava
D. Supraspinous ligament
E. Anterior longitudinal ligament
85 An orthopedic surgeon was teaching two residents during a workshop. For the purpose of learning,
one resident acted as the patient and the other as the
clinician. The surgeon asked the resident-clinician to
use a marker and draw a horizontal line connecting the
highest points of the iliac crests on the skin of the
resident-patient. The surgeon then asked the residentclinician to palpate the midline area on the skin where
the subarachnoid space terminates inferiorly. Which of
the following most likely represents the area on the skin
where the resident-physician palpated?
A. Three spinous processes superior to the
horizontal line
B. Two spinous processes inferior to the
horizontal line
C. Three spinous processes inferior to the
horizontal line
D. Two spinous processes superior to the
horizontal line
E. The spinous process bisected by the
horizontal line
86 An MRI scan of the thoracic spine of a 68-year-old
man with acute midback pain revealed a large tumor
arising from the anterior median fissure of the spinal
cord at the level of the T3 vertebra. The artery compressed by the tumor is most likely formed superiorly
by direct branches from which of the following
arteries?
A. Ascending cervical
B. Segmental medullary
C. Vertebral
D. Segmental spinal
E. Posterior spinal

87 Radiographs of a 12-year-old girl with midback
pain reveal a hemivertebra of the lower thoracic spine.
Which additional finding would most likely be demonstrated on the radiographs?
A. Osteoporosis
B. Scoliosis
C. Hyperlordosis
D. Spondylolisthesis
E. Sacralization
88 In a report of a radiograph of the cervical spine
the radiologist wrote the following: “Severe narrowing
of the C7-T1 intervertebral foramen (IVF) on the left.”
Which nerve was most likely compressed as a result of
this finding?
A. C6
B. C7
C. C8
E. T1
89 A mother brought her 15-month-old previously
healthy child to the pediatrician and nervously told the
physician that her child now had “a curvature in her
low back.” The mother stated that this curvature was
not present previously and that she noticed it when the
child started standing and walking. The physician
examined the child and then reassured the mother that
the spinal curvature was normal. Which curvature did
the mother most likely observe?
A. Thoracic kyphosis
B. Cervical lordosis
C. Lumbar lordosis
D. Cervical kyphosis
E. Thoracic lordosis
90 During a gross anatomy laboratory session, a professor demonstrates a large back muscle that inserts
onto the floor of the intertubercular sulcus of the
humerus. Which of the following structures is most
likely the vertebral origin of the muscle that the professor is demonstrating?
A. Spinous processes of T7 to L5
B. Spinous processes of C7 to T12
C. Transverse processes of C1 to C4
D. Spinous processes of T2 to T5
E. Spinous processes of C7 and T1
91 A drug that preferentially destroys sclerotomes
during embryogenesis would most likely result in

15

Back
underdevelopment of which of the following
structures?
A. Nucleus pulposus of intervertebral disc
B. Vertebral bodies
C. Dorsal root ganglion
D. Spinal cord
E. Anulus fibrosus of intervertebral disc
92 Which of the following muscles is most likely
located immediately deep to the semispinalis muscles,
pass from a lateral point of origin in a superomedial
direction to attach to spinous processes, and cross
between 2 and 4 vertebrae?
A. Multifidus
B. Rotatores
C. Longissimus
D. Iliocostalis
E. Spinalis
93 A 32-year-old construction worker falls from a
scaffold and is brought to the emergency department
with severe lower back pain. Radiographs of the lumbar
spine reveal bilateral pars interarticularis fractures of
the L5 vertebra. Which of the following radiographic
views would most likely reveal these fractures?
A. Anteroposterior
B. Lateral
C. Posteroanterior
D. Oblique
E. Anteroposterior open mouth
94 A radiology report of a cervical spine MRI scan
contains the following statement: “A small 1-cm tumor
is located within a muscle on the lateral border of the
right suboccipital triangle.” The muscle to which the
radiologist is most likely referring inserts on which of
the following bony features?
A. Transverse process of atlas
B. Lateral portion of occipital bone below
inferior nuchal line
C. Occipital bone between superior and inferior
nuchal lines
D. Medial portion of occipital bone below
inferior nuchal line
E. Posterior tubercle of atlas
95 Radiographs of the lumbar spine of a 68-year-old
woman with lower back pain were taken and in the
radiology report the following was written: “The anteroposterior view demonstrates marked bilateral enlarge16 ment of the transverse processes of a single vertebra.

The length and width of both transverse processes of
this single vertebra are enlarged and the inferior aspects
of these bony features appear to be articulating with
the bone immediately below it, so much so that the
single vertebra appears to have morphologic characteristics similar to the bone immediately below it.” The
single vertebra referred to by the radiologist in the
report is most likely which of the following?
A. L1 vertebra
B. L4 vertebra
C. S2 vertebra
D. S1 vertebra
E. L5 vertebra
96 A 45-year-old man was injured in a motor vehicle
crash and brought to the emergency department. Radiographs of the upper cervical spine revealed a type III
dens fracture demonstrated by a horizontal radiolucent
line on the superior half of the posterior aspect of the
C2 vertebral body. Which of the following ligaments
most likely has direct attachment to the bony area
where the fracture was located?
A. Apical ligament of dens
B. Superior longitudinal band of cruciform
ligament
C. Transverse ligament of atlas
D. Inferior longitudinal band of cruciform
ligament
E. Ligamenta flava
97 A 35-year-old man underwent a laminectomy of
the T8 to T9 vertebrae. During the surgery, the neurosurgeon observed that the posterior roots were compressed at that level due to a space-occupying lesion.
Which of the following arteries was most likely directly
compressed by the lesion?
A. Radicular
B. Segmental spinal
C. Segmental medullary
D. Anterior spinal
E. Posterior spinal
98 An 8-year-old girl was brought to a pediatrician
for a routine physical examination. The figure associated with this question is a photograph of the child
(Fig. 1-4). Which of the following best describes the
embryologic basis for this child’s condition?
A. Underdevelopment of the secondary
ossification center in the vertebral arch
B. Underdevelopment of the primary ossification
center in the spinous process

Back
100 A 38-year-old woman has been in labor for 14
hours and has agreed to have an epidural anesthetic
injection for pain control. Which of the following structures is most likely to be the last penetrated by the
needle before it reaches the epidural space?
A. Supraspinous ligament
B. Interspinous ligament
C. Anterior longitudinal ligament
D. Posterior longitudinal ligament
E. Ligamenta flava

Fig. 1-4

C. Underdevelopment of the primary ossification
center in the vertebral body
D. Underdevelopment of the secondary
ossification center in the vertebral body
E. Underdevelopment of the primary ossification
center in the vertebral arch
99 The following statement is written in the radiology report of an MRI scan of the cervical spine: “A large
osteophyte is emanating from the posterolateral area of
the vertebral body of the vertebra immediately above
the C3 nerve root and is severely compressing the C3
nerve root.” The osteophyte is most likely emanating
from which of the following vertebrae?
A. C2
B. C3
C. C4
D. C5
E. C1

101 A 48-year-old man underwent suboccipital surgery
whereby the surgeon made a midline incision through
the ligamentum nuchae that began 1-cm inferior to the
external occipital protuberance and ended at the level
of the C2 vertebra. The surgeon then placed self-retaining retractors into the incision to forcibly separate the
tissue so that an adequate surgical field existed for the
duration of the surgery which lasted for 3 hours. During
recovery, the patient complained of severe occipital
pain and was diagnosed with postsurgical occipital
neuralgia. Which of the following nerves was most
likely directly stretched by the retractors during the
surgery and resulted in this patient’s post-surgical pain?
A. Third occipital
B. Suboccipital
C. Greater occipital
D. Lesser occipital
E. Spinal accessory
102 A 7-year-old boy is undergoing a surgery to
remove a tumor from his spinal cord. During surgery
of the spinal cord, which of the following structures is
used as a landmark to identify anterior rootlets from
posterior rootlets?
A. Denticulate ligament
B. Filum terminale
C. Conus medullaris
D. Posterior longitudinal ligament
E. Ligamenta flava
103 A 45-year-old male driver involved in a motor
vehicle crash was taken to the emergency department
and MRI revealed a complete tear of the right alar ligament. None of the other ligaments of the upper cervical
spine were torn. Upon physical examination, which of
the following cervical spine movements will be most
likely increased as a result of the tear?
A. Flexion
B. Extension
C. Lateral flexion

17

Back
D. Rotation
E. Abduction
104 A 25-year-old male bodybuilder complains of difficulty moving his right shoulder for the past 2 weeks.
Upon physical examination, the muscles of the left
upper back and shoulder were notably larger than the
right side. There was a notable decrease of muscle
power on his right sided upper back and shoulder
muscles when he was asked to pull the shoulder blades
toward the middle of his back against resistance. Nerve
conduction examination confirmed neurapraxia of the
nerves supplying the rhomboid major and minor
muscles. In which of the following functions will the
bodybuilder most likely also demonstrate weakness?
A. Abduction of the right arm above the
horizontal level and protraction of the scapula
B. Medial rotation and adduction of the right
arm
C. Extensions, adduction, and medial rotation of
the right arm
D. Elevation of the scapula and inferior rotation
of the right shoulder
E. Abduction of the right arm from 0 to 15
degrees
105 A 38-year-old woman with a history of carcinoma
of the left breast and who had had a lumpectomy 2
years previously, presents to her surgeon with complaints of a hard mass in the left breast. On ultrasound
examination, a 3 cm × 4 cm hard mass is discovered
in the upper outer quadrant extending in the axillary
tail (of Spence). A radical mastectomy is performed
successfully and the tumor is removed. Three weeks
postoperatively the patient complains of difficulty
raising her left arm above her head. Which of the following is most likely expected to be found during physical examination?
A. Protraction of the both scapulae
B. Protrusion of the medial border of the left
scapula when hands are pushed against the
wall
C. Weak abduction of the left upper limb in the
15 to 90 degree range
D. Weak retraction of the scapula
E. Weak adduction of the humerus
106 A 2-month-old infant is admitted to the emergency department with symptoms of meningitis. A
lumbar puncture is performed in order to examine the
CSF to confirm the diagnosis. The needle is inserted
into the lumbar cistern (dural sac). At which vertebral

18

level will the conus medullaris typically be found in
this patient?
A. L3
B. L4
C. L5
D. S1
E. S2
107 Examination of a 3-day-old male infant reveals a
large cystic of approximately 15 cm × 10 cm in the
sacrococcygeal region. The mass was removed and histopathological studies identified tissue from all three
embryological germ layers. Which of the following
embryonic tissues is most likely responsible for this
condition?
A. Remnants of the primitive streak
B. Chorionic villi
C. Neural folds
D. Intraembryonic coelom
E. Neural crest
108 A 53-year-old man is admitted to the emergency
department with severe back pain. MRI examination
reveals fracture of the pars interarticularis and normal
alignment of the body of the L5 vertebra upon the
sacrum. What is the most likely diagnosis?
A. Spondylolysis
B. Spondylolisthesis
C. Herniation of intervertebral disc
D. Lordosis
E. Scoliosis
109 A 22-year-old pregnant woman underwent epidural anesthesia in anticipation of labor. After delivery
she developed back pain and right lower extremity
weakness. Imaging revealed a hematoma in the epidural space resulting in compression of the nerve that
exits at the level of L2 to L3. Which of the following
vessels is most likely responsible for the hematoma?
A. Internal vertebral plexus
B. Great radicular artery (of Adamkiewicz)
C. Anterior spinal artery
D. Posterior spinal artery
E. External vertebral plexus
110 Idling at a stoplight in his vintage car without
headrests, a 71-year-old-man’s car is struck from behind
by a truck. The man is brought to the emergency
department suffering from a severe hyperextension
neck injury due to the crash. The T2-weighted MRI

Back
shows a rupture of the anterior anulus fibrosus of the
C4 to C5 intervertebral disc and a prevertebral hematoma which compromised his airway and required intubation. Which of the following ligaments is most likely
disrupted in this injury?
A. Anterior longitudinal ligament
B. Posterior longitudinal ligament
C. Ligamentum flavum
D. Interspinous ligament
E. Intertransverse ligament
111 An anesthesiologist administers epidural anesthetic immediately lateral to the spinous processes of
vertebrae L3 and L4 of a pregnant woman in labor.
During this procedure, what would be the last ligament
perforated by the needle in order to access the epidural
space?
A. Ligamentum flavum
B. Anterior longitudinal ligament
C. Posterior longitudinal ligament
D. Interspinous ligament
E. Intertransverse ligament
112 A 38-year-old man presents to the emergency
department with complaints of lower back pain during
the past 5 days. Examination revealed tenderness of the
spine over the L5 vertebra with an obvious “step-off”
defect at that level. There was some weakness of the
limbs. An MRI examination revealed an anterior displacement of the L5 vertebral body and narrowing of
the vertebral canal. This pathology will most likely be
associated with which of the following?
A. Compression of the spinal cord and bilateral
lower limb weakness
B. Compression of the spinal cord and unilateral
lower limb weakness
C. Compression of the spinal nerve roots and L5
with unilateral lower limb weakness
D. Compression of the cauda equina and
bilateral lower limb weakness
E. Compression of the cauda equina and low
back pain only
113 A 62-year-old man visits his physician for his
annual medical check-up. During physical examination
it is noted that the patient has noticeable pulsations on
palpation of the lower abdomen. Ultrasound examination reveals a large abdominal aortic aneurysm. The
patient is operated on and during the repair his aorta
is temporarily clamped. Which of the following arterial

anastomoses will most likely prevent ischemia of the
spinal cord if the blood pressure drops dangerously
low?
A. Segmental arteries from the vertebral,
intercostals, superficial epigastric, lumbar,
and medial sacral arteries
B. Segmental arteries from the vertebral,
intercostal, lumbar, spinal anterior, and
posterior and lateral sacral arteries
C. Anterior and posterior spinal arteries
D. Radicular arteries of the vertebral, lumbar,
intercostal, lateral sacral arteries, and artery
of Adamkiewicz
E. Segmental arteries from vertebral and
intercostals
114 A 22-year-old woman is diagnosed with the presence of a chondroma at her index finger. Which of the
following structures are sharing the same embryologic
with the tumor?
A. Denticulate ligament
B. Dentate ligament
C. Nucleus pulposus
D. Apical ligament of the atlas
E. Alar ligament
115 A 40-year-old woman survived a car crash in
which her neck was hyperextended when her vehicle
was struck from behind. At the emergency department
a plain radiograph of her cervical spine is shown below
(Fig. 1-5). Which of the following was also most likely
injured?
A. Anterior arch of the atlas
B. Posterior tubercle of the atlas
C. Atlanto-occipital joint
D. Inferior articular process of the axis
E. Anterior tubercle of the atlas
116 A 32-year-old man was lifting heavy weights
during an intense training session. He felt severe pain
radiating to the posterior aspect of his right thigh and
leg. He was taken to hospital where an MRI scan (see
Fig. 1-3) revealed a ruptured intervertebral disc. Which
of the following nerves was most likely affected?
A. L2
B. L3
C. L4
D. L5
E. S1

19

Back

B

A

C

Fig. 1-5

ANSWERS
1 B. Hyperkyphosis is characterized by a “hunchback” due to an abnormal increase in curvature of the
thoracic region of the vertebral column. Hyperlordosis, or “swayback,” is an increase in lumbar curvature
of the spine. Lordosis can be physiologic, such as seen
in a pregnant woman. Scoliosis is a lateral curvature
of the spine with rotation of the vertebrae. Spina
bifida is a neural tube defect characterized by failure
of closure of the vertebral arch. Osteoarthritis is a
degenerative disorder that affects the articular carti-

20

lage of joints and is not specifically related to the
thoracic region of the spine.
GAS 76; N 153; McM 97
2 B. A crush fracture is characterized by compression of the entire vertebral body. The wedge fracture
is similar in that it affects the vertebral bodies, but
it involves small fractures around the perimeter of
the vertebral body. Both of these fractures cause
reductions in overall height. Fracture of the spinal,
transverse, or superior articular processes can be due
to an oblique, transverse, or comminuted fracture.

Back
Intervertebral discs are associated with disc herniation, not compression fractures.
GAS 82; N 153-154; McM 88, 107
3 C. The ligamentum flavum connects the laminae
of two adjacent vertebrae and forms the posterior wall
of the vertebral canal. It is the only answer choice
that is in direct contact with the vertebral foramen.
Therefore, hypertrophy of only the ligamentum flavum
would present as spinal canal stenosis. The supraspinous and interspinous ligaments connect spinous processes. The anterior longitudinal ligament connects
the anterior portion of the vertebral bodies and intervertebral discs. Finally, the nuchal ligament is a thickened extension of the supraspinous ligament above
the level of C7.
GAS 84; N 159; McM 99
4 C. The dorsal scapular nerve (from the ventral
ramus of C5) is responsible for innervating rhomboids
major and minor. The rhomboids are responsible for
retraction of the scapula. Therefore, if this nerve is
damaged, individuals present with a laterally displaced scapula. In this case, the levator scapulae
remains functional due to additional innervation provided by C3 to C4 spinal nerves. The axillary nerve
innervates the deltoid and teres minor muscles. The
deltoid muscle abducts the humerus, and the teres
minor laterally rotates the humerus. The long thoracic
nerve innervates the serratus anterior, which functions to protract and upwardly rotate the scapula. The
greater occipital nerve is mainly sensory but also
contributes to the innervation of the semispinalis
capitis. In addition, the greater occipital nerve can be
involved in occipital neuralgias. The suprascapular
nerve innervates the supraspinatus and infraspinatus
muscles. The supraspinatus abducts the humerus,
and the infraspinatus muscles laterally rotate the
humerus. Injury to any of these other nerves would
not present with a laterally retracted scapula.
GAS 90; N 174; McM 133

the L4 and L5 vertebrae, it exits from the spinal canal
superior to the intervertebral disc, whereas the L5
spinal nerve root lies directly posterior to the disc.
GAS 79; N 161; McM 97
7 D. A lumbar puncture is performed by taking a
sample of CSF from the lumbar cistern (the subarachnoid space below the spinal cord) between vertebrae
L4 and L5 or sometimes between L3 and L4. It is done
in this region because the spinal cord typically ends
at the level of L1 to L2 and the dural sac ends at the
level of S2. Therefore, it is the safest place to do the
procedure because it lies between these areas and the
risk of injuring the spinal cord is minimized. (Remember in children the cord ends more caudally.)
GAS 116; N 160-161; McM 97
8 B. The highest points of the iliac crests are used
as a landmark for locating the position of L4 to L5 for
a lumbar puncture; they are identified and traced
medially toward the vertebral column (Tuffier’s line).
The inferior angles of the scapulae lie at vertebral
level T7; the lowest ribs lead one to T12; the sacral
hiatus is located lower at the distal portion of the
sacrum; the posterior inferior iliac spines lie below
S2.
GAS 106, 114-116; N 160-161; McM 97
9 A. The anterior longitudinal ligament lies anterior
to the vertebral bodies along the vertebral column.
The ligamentum flavum connects the laminae of two
adjacent vertebrae. The nuchal ligament is a continuation of the supraspinous ligament above C7, which
connects spinous processes. The posterior longitudinal ligament lies on the posterior margin of the
vertebral bodies. The transverse cervical (cardinal)
ligament is associated with the pelvic region of the
body and not the spinal column (GAS Figs. 2-31 and
2-34).
GAS 80; N 159; McM 98

5 B. Herpes zoster is a viral disease that remains
latent in the dorsal root ganglia of the sensory nerves
and when the virus becomes active presents as a
painful skin lesion. It is associated only with sensory
nerve fibers and has no motor involvement. The only
answer choice that is solely responsible for sensory
innervation is the dorsal root ganglion.
GAS 109; N 161-162; McM 95

10 B. Compression of nerves at the intervertebral
foramen indicates a disc herniation. A disc herniation
is characterized by protrusion of the nucleus pulposus
through the anulus fibrosus posterolaterally into the
spinal canal or intervertebral foramen. In general, the
ligaments may be affected by the herniation but are
not responsible for the compression of the spinal
nerve roots.
GAS 79; N 158; McM 99

6 E. Disc herniation in the lumbar region between
L4 and L5 affects the L5 spinal nerve roots. Even
though the L4 spinal nerve root lies directly between

11 A. The thoracodorsal nerve innervates the latissimus dorsi, one of major muscles that adduct and
medially rotate the humerus. The axillary nerve

21

Back
Posterior longitudinal ligament

Ligamentum flavum
Supraspinous ligament
Interspinous ligament

Anterior longitudinal ligament

GAS Fig. 2-31

Ligamentum flavum

Supraspinous ligament

GAS Fig. 2-34
supplies the deltoid muscle, the dorsal scapular nerve
supplies the rhomboids and levator scapulae muscles,
and the spinal accessory nerve innervates the trapezius. None of these nerves medially rotates or adducts
the humerus. The radial nerve is responsible for the
innervation on the posterior aspect of the arm and
forearm. The medial and lateral pectoral nerves and
the lower subscapular nerve supply the other medial
rotators of the humerus.
GAS 87, 99; N 174; McM 101
12 C. The long thoracic nerve innervates the serratus anterior, which is responsible for elevation and
protraction of the scapula beyond the horizontal level
while maintaining its position against the thoracic
wall. Along with the thoracodorsal nerve, the long
thoracic nerve runs superficially along the thoracic
wall and is subject to injury during a mastectomy
procedure. The axillary nerve, the spinal accessory
nerve, and the thoracodorsal nerve supply the deltoid

22

muscle, trapezius muscle, and latissimus dorsi
muscles, respectively. The dorsal scapular nerve is
responsible for innervation of the rhomboids and
levator scapulae. Aside from the long thoracic and
thoracodorsal nerves, the remaining nerves do not
course along the lateral thoracic wall.
GAS 726; N 180, 413; McM 140
13 D. The rotator cuff muscles are common sites
of damage during shoulder injuries. These muscles
include the supraspinatus, infraspinatus, teres minor,
and subscapularis (SITS). Initiation of abduction of
the humerus (the first 15 degrees) is performed by the
supraspinatus, followed by the deltoid from 15 to 90
degrees. Above the horizontal, the scapula is rotated
by the trapezius and serratus anterior muscles, causing
the glenoid fossa to turn superiorly and allowing the
humerus to move above 90 degrees. The teres major

Back
and the pectoralis major are responsible for medial
rotation and adduction of the humerus. These muscles
are therefore not involved in abduction at the glenohumeral joint.
GAS 711-712, 717; N 134-135; McM 411, 413
14 C. Spina bifida is a developmental condition
resulting from incomplete fusion of the vertebral
arches within the lumbar region. Spina bifida occulta
commonly presents asymptomatically with midline,
lumbar, cutaneous stigmata such as a tuft of hair and
a small dimple. More severe forms (spina bifida
cystica) are categorized into three types: Spina bifida
cystica with meningocele presents with protrusion of
the meninges through the unfused vertebral arches;
spina bifida with myelomeningocele is characterized
by protrusion both of the meninges and central
nervous system (CNS) tissues and is often associated
with neurologic deficits; and rachischisis, also known
as spina bifida cystica with myeloschisis, results from
a failure of neural folds to fuse and is characterized
by protrusion of the spinal cord or spinal nerves and
meninges.
GAS 74; N 14, 160; McM 77, 88
15 A. Somatic afferents are responsible for conveying pain, pressure, touch, temperature, and proprioception to the CNS. Afferent fibers carry only sensory
stimuli, whereas efferent fibers convey motor information. Visceral innervation is associated with the
autonomic nervous system. Visceral afferents generally carry information regarding the physiologic
changes of the internal viscera whereas visceral efferents deliver autonomic motor function to three types
of tissue: smooth muscle, cardiac muscle, and glandular epithelium.
GAS 32-35; N 174; McM 211
16 E. CSF is found within the subarachnoid space
and is continuous with the ventricles of the brain (CSF
flows from the ventricles to the subarachnoid space).
The epidural space, positioned between the dura
mater and periosteum, contains fat and the internal
vertebral venous plexus (of Batson). The subdural
space, between the arachnoid mater and dura mater,
exists only as a potential space and does not contain
cerebrospinal fluid. The anterior and posterior longitudinal ligaments traverse the length of the vertebral
bodies.
GAS 106, 114-116; N 166; McM 97
17 B. The posterior longitudinal ligament is the
only ligament spanning the posterior aspect of the
vertebral bodies and intervertebral discs. With inter-

vertebral disc herniation, the nucleus pulposus of
the intervertebral disc protrudes posterolaterally. The
anterior longitudinal ligament traverses the anterior
side of the vertebral bodies and thus would not protect
the spinal cord from direct compression. The supraspinous and ligamentum flavum ligaments connect
the spinous processes and the laminae of adjacent
vertebrae, respectively. The nuchal ligament is a continuation of the supraspinous ligaments near the C7
vertebrae and runs to the occipital protuberance.
GAS 80-81; N 159; McM 94
18 C. This is the location of the conus medullaris,
a tapered conical projection of the spinal cord at its
inferior termination. Although the conus medullaris
rests at the level of L1 and L2 in adults, it is often
situated at L3 in newborns. The cauda equina and
filum terminale extend beyond the conus medullaris.
GAS 99, 100; N 161; McM 97
19 A. The sympathetic division of the autonomic
nervous system is primarily responsible for vasoconstriction. Separation of ventral or dorsal roots would
lead to undesired consequences, such as a loss of
motor or sensory activity. Similarly, surgical division
of spinal nerves would also have unwanted consequences, but such are not related to the increased
arterial constriction and the painful ischemia in the
digits. Division of selected sympathetic chain ganglia,
however, would decrease the sympathetic outflow to
the upper limbs.
GAS 38-39; N 163; McM 94-95
20 D. The diaphragm is innervated by the phrenic
nerve, which arises from C3 to C5. The rhomboid,
serratus anterior, supraspinatus, and latissimus dorsi
are innervated by the ventral rami of the brachial
plexus (C5 to T1).
GAS 161-162; N 161; McM 194
21 C. The anterior longitudinal ligament runs along
the anterior-most aspect of the vertebral column from
C1 to the sacrum and would therefore be unaffected
by a laminectomy. Denticulate ligaments extend laterally from the pia mater to the arachnoid mater along
the length of the spinal cord. The ligamentum flavum
is one of the two ligaments found in the vertebral
canal and is adherent to the anterior aspect of the
vertebral arches and often greatly thickened in spinal
pathology. It is thus simultaneously removed upon
excision of the lamina. The nuchal ligament is a thick
longitudinal extension continuing from the supraspinous ligament at the level of C7 to the external

23

Back
occipital protuberance (inion). The cruciate ligament
is an incorrect answer because it is located anterior
to the spinal cord, and thus would not be involved in
laminectomy.
GAS 80; N 159; McM 98
22 C. The vertebral canal is the longitudinal canal
that extends through the vertebrae, containing the
meninges, spinal cord, and associated ligaments. The
internal vertebral venous plexus is the mostly valveless network of veins extending longitudinally along
the vertebral canal. Neither of these answer choices
describes a specific space. The spinal epidural space
is found superficially to the dura mater. It is a fat-filled
space extending from C1 to the sacrum. The subarachnoid space is a true space containing CSF. It is found
within the CNS and extends to the level of S2. The
subdural space is a potential space between the dura
and the arachnoid mater. Normally, these two layers
are fused due to the pressure of CSF in the subarachnoid space.
GAS 103-110; N 166; McM 94, 96
23 A. Lumbar puncture is generally performed at
the level of L4 or L5. The supraspinous ligament
extends between spinous processes on the dorsal
aspect of the vertebrae. The needle will bypass this
structure. The denticulate ligaments are not correct
because they terminate with the conus medullaris at
the level of L2 and are located laterally. The anterior
longitudinal ligament extends along the most anterior
aspect of the vertebral bodies and can be reached only
ventrally. The posterior longitudinal ligament is
present at the correct vertebral level but will be punctured only if the procedure is performed incorrectly
as in this case, where hematopoietic cells were aspirated from the vertebral body anterior to the ligament.
The nuchal ligament extends cranially from the supraspinous ligament in the lower cervical region to the
skull.
GAS 103-110; N 159; McM 94, 96
24 B. The anterior spinal artery is located anteriorly
along the spinal cord and is not directly associated
with the vertebrae. The vertebral arteries run through
the transverse foramina of cervical vertebrae C6
through C1 and are therefore most closely associated
with injury to the transverse processes. The ascending
cervical artery is usually a very small branch from the
thyrocervical trunk of the subclavian artery, running
on the anterior aspect of the vertebrae. The deep
cervical artery arises from the costocervical trunk and
is also a very small artery and courses along the posterior aspect of the cervical vertebrae. The posterior

24

spinal arteries are adherent to the posterior aspect of
the spinal cord.
GAS 100; N 167; McM 94-95
25 B. Scoliosis is defined as a lateral deviation of
the spinal column to either side. Hyperkyphosis is an
increased primary curvature of the spinal column.
This curvature is associated with thoracic and sacral
regions and is most likely this patient’s clinical condition. Spinal stenosis is a narrowing of the vertebral
canal and is not directly associated with a displacement of the spinal column. Hyperlordosis is the
increased secondary curvature affecting the cervical
and lumbar regions. A herniated disc is a rupture of
the anulus fibrosus of the intervertebral disc, commonly causing a posterolateral displacement of the
nucleus pulposus into the vertebral canal.
GAS 75; N 153; McM 87
26 B. The thoracodorsal nerve innervates the latissimus dorsi, which has no direct action on the shoulder girdle. The spinal accessory nerve is the eleventh
cranial nerve (CN XI) and innervates both the trapezius and sternocleidomastoid muscles. The loss of CN
XI results in drooping of the shoulder due to paralysis
of the trapezius. In addition to the clinical findings of
the MRI, one can test the innervation of this nerve by
asking the patient to shrug his or her shoulders against
resistance (testing the trapezius), as well as turning
his or her head against resistance (testing the sternocleidomastoid). The dorsal scapular nerve usually
innervates the levator scapulae muscle and the rhomboid muscles. The greater occipital nerve is primarily
a sensory nerve innervating the posterolateral aspect
of the scalp. The axillary nerve is a branch of the brachial plexus and innervates the deltoid and teres minor
muscles. It is not involved in shoulder elevation.
GAS 87, 99; N 171; McM 101
27 B. The anterior longitudinal ligament runs on
the anterior aspect of the vertebrae and is not affected.
The transverse ligament of the atlas anchors the dens
laterally to prevent posterior displacement of the
dens. This ligament has been torn in this injury. The
ligamentum flavum is found on the posterior aspect
of the vertebral canal and does not contact the anteriorly placed dens. The supraspinous ligament is
located along the spinous processes of the vertebrae.
The nuchal ligament is a longitudinal extension of the
supraspinous ligament above the level of C7.
GAS 80; N 159; McM 97
28 B. The iliocostalis thoracis muscle is found in
the deep back and functions to maintain posture. It is

Back
not associated with neck flexion. The sternocleidomastoid muscle is innervated by CN XI and functions
in contralateral rotation (unilateral contraction) and
flexion (bilateral contraction) of the neck. Rhomboid
major and minor are both innervated by the dorsal
scapular nerve and serve to adduct the scapulae.
Teres major is innervated by the lower subscapular
nerve and serves to medially rotate and adduct the
humerus.
GA 93-97; N 171; McM 101
29 C. The pedicles are bony structures connecting
the vertebral arches to the vertebral body. The ligamentum flavum runs on the posterior aspect of the
vertebral canal and is more closely associated with
the laminae than to the pedicles of the vertebrae. The
nuchal ligament is a longitudinal extension of the
supraspinous ligament from C7 to the occiput, both
running on the most posterior aspect of the vertebrae
along the spinous processes. The cruciform (also
called cruciate or transverse ligament of the atlas)
ligament is a stabilizing ligament found at the skull
base and C1/C2. It attaches to the pedicles and helps
stabilize the dens. The posterior longitudinal ligament
extends the length of the anterior aspect of the vertebral canal and is anterior to the pedicles.
GAS 68-69; N 23; McM 85
30 A. Spondylolysis is the anterior displacement of
one or more vertebrae. This is most commonly seen
with the cervical vertebrae because of their small size
and structure and the oblique angle of the articular
facets. Lumbar vertebrae are somewhat susceptible to
this problem because of the pressures at lower levels
of the spine and the sagittal angles of the articular
facets. It is much less common in the thoracic vertebrae due to the stabilizing factor of the ribs. It is not
seen in the sacral vertebrae because they are fused
together.
GAS 82-83; N 153; McM 86
31 D. The internal vertebral plexus (of Batson) surrounds the dura mater in the spinal epidural space;
hence the bleeding would cause the hematoma in that
space. The subarachnoid space, containing the CSF,
is located between pia and arachnoid mater. A subarachnoid hemorrhage would most likely result from
a ruptured intercerebral aneurysm. A subdural hematoma would result most likely from a venous bleed
from a torn cerebral vein as it enters the superior
sagittal venous sinus within the skull. The central
canal is located within the gray matter of the spinal
cord. The lumbar cistern is an enlargement of the
subarachnoid space between the conus medullaris of

the spinal cord and the caudal end of the subarachnoid space.
GAS 102; N 169; McM 108
32 D. In the lumbar region spinal nerves exit the
vertebral column below their named vertebrae. In an
L4, L5 intervertebral disc herniation, the L5 spinal
nerve would be affected as it descends between L4,
L5 vertebrae to exit below the L5 level. L2, L3, and
L4 spinal nerves have already exited above the level
of herniation; therefore, they would not be affected
by this herniation. An “L6” spinal nerve normally
does not exist. (The National Board of Medical Examiners does not allow “made up” structures, but in
cases of lumbarization of S1, some people recognize
an L6 nerve.)
GAS 79, 108; N 161; McM 97
33 E. Posterior intercostal arteries supply the deep
back muscles, which are responsible for extending
and laterally bending the trunk. The subscapular
artery supplies the subscapularis muscle, the thoracodorsal artery supplies the latissimus dorsi, the anterior intercostal supplies the upper nine intercostal
spaces, and the suprascapular artery supplies the
supraspinatus and infraspinatus muscles. These
muscles are not responsible for extension and lateral
flexion of the trunk.
GAS 100-101; N 168; McM 102
34 A. The atlantoaxial joint is a synovial joint
responsible for rotation of the head, not flexion,
abduction, extension, or adduction. The atlantooccipital joint is primarily involved in flexion and
extension of the head on the neck.
GAS 71; N 19; McM 85
35 D. The internal vertebral plexus (of Batson) lies
external to the dura mater in the epidural space. To
aspirate excess blood, the physician must pass the
needle through the ligamentum flavum to reach the
epidural space wherein the blood would accumulate.
The spinal cord, pia mater, and arachnoid mater are
located deep to the epidural space.
GAS 102; N 169; McM 97
36 E. The T4 thoracic vertebra articulates with the
head of the fifth rib. The head of the rib has two
facets. The rib articulates with the superior facet on
the body of its own vertebra (the fourth rib articulates
with the superior facet T4 vertebra) and with the
inferior facet on the body of the vertebra above (the
fourth rib articulates with the inferior facet of T3
vertebra). Taking the T4 vertebra into consideration,

25

Back
the superior facet of this vertebra articulates with the
head of the fourth rib and the inferior facet articulates
with the head of the fifth rib. The head of the fourth
rib has two points of articulation (a joint with the
vertebral body and a costotransverse joint) on T4, so
when it is injured it moves as a unit, whereas the fifth
rib has only one articulation with T4.
GAS 124; N 183; McM 174
37 E. The teres major is responsible for adduction
and medial rotation of the humerus, the teres minor
is responsible for lateral rotation of the humerus, the
triceps brachii is responsible for extension of the
forearm, the supraspinatus is responsible for the first
0 to 15 degrees of abduction, and the infraspinatus is
a lateral rotator.
GAS 717; N 171; McM 103
38 B. The infraspinatus is responsible for lateral
rotation of the humerus (along with the teres minor,
not a choice here). The teres major is responsible for
adduction and medial rotation of the humerus. The
latissimus dorsi is responsible for adduction, extension, and medial rotation of the humerus. The trapezius is an elevator of the scapula and rotates the
scapula during abduction of the humerus above the
horizontal plane. The supraspinatus is responsible for
the first 0 to 15 degrees of abduction.
GAS 717; N 171; McM 102
39 A. When a lumbar puncture is performed, the
needle must penetrate the ligamentum flavum, the
dura mater, and finally the arachnoid mater to reach
the subarachnoid space where the CSF is located. The
lumbar cistern is a continuation of the subarachnoid
space below the conus medullaris. The pia mater is
adherent to the spinal cord, and the posterior longitudinal ligament is attached to the posterior aspect of
the vertebral bodies.
GAS 106, 114-116; N 161; McM 97
40 C. The subarachnoid space, containing the CSF,
is located between the pia and the arachnoid mater.
Neither the epidural space, the subdural space, nor
the pretracheal space contains CSF. Although the
central canal, contained within the substance of the
spinal cord, does contain CSF, extraction of CSF from
this space would result in spinal cord injury. CSF
circulates within the subarachnoid space and can be
aspirated only from that location. The subdural space
is only a potential space between the dura and arachnoid mater. The epidural space contains the epidural
fat and Batson’s venous plexus and is the site to

26

inject an anesthetic for epidural anesthesia. CSF is not
located in the pretracheal space.
GAS 106; N 166; McM 97
41 A. General somatic afferent fibers are conveyed
from the skin of the back via the dorsal primary rami.
Communicating rami contain general visceral efferent
(sympathetic) fibers and general visceral afferent
fibers of the autonomic nervous system. Ventral
primary rami convey mixed spinal nerves to/from all
other parts of the body excluding the back, and parts
of the head innervated by cranial nerves. The ventral
roots contain only efferent (motor) fibers. Intercostal
nerves are the ventral rami of T1 to T11. The ventral
ramus of T12 is the subcostal nerve.
GAS 32-48; N 177; McM 98
42 D. The conus medullaris is usually located at the
L1 to L2 vertebral level; therefore, any choice that
contains that region is the correct answer. L3 to L4 is
a common location to perform lumbar puncture, but
it is caudal to the apex of the conus medullaris. L3
and L4 are caudal to the conus medullaris. T11 is
superior to the conus medullaris.
GAS 99-110; N 161, 163, 164; McM 97
43 D. Because the meninges and spinal cord are
included in the protrusion, the patient’s condition is
a classic presentation of spina bifida with myelomeningocele. If the protrusion contains only meninges
but no CNS tissue, it is known as spina bifida with
meningocele. Meningitis is an inflammation of the
meninges caused by bacteria, viral, or numerous other
irritants (e.g., blood). It does not cause deformation
of the vertebrae or result in protrusion of spinal cord
contents. Spina bifida occulta is a normally asymptomatic condition in which the vertebral laminae fail
to fuse completely during embryologic development.
A tuft of hair is commonly seen growing over the
affected region (usually lumbar in position).
GAS 74; N 160; McM 97
44 C. Somatic afferent fibers convey localized pain,
typically from the body wall and limbs. Visceral afferents convey autonomic nervous system sensory information. Pain from these fibers will present as dull and
diffuse. Somatic efferent fibers convey motor information to skeletal muscle. Sympathetic preganglionic
fibers are visceral efferent fibers and do not contain
sensory information. Parasympathetic preganglionic
fibers are also visceral efferents and do not contain
sensory information.
GAS 32-48; N 174; McM 97

Back
45 B. Lateral flexion is the best answer because
other movements of the lumbar portion of the vertebral column are very limited due to the orientation of
the articular facets.
GAS 64-73; N 155; McM 97
46 D. Batson’s venous plexus, in general, is a valveless network of veins located in the epidural space of
the vertebral canal. The lack of valves can provide a
route for the metastasis of cancer (e.g., from prostate
or breast to brain) because the flow of blood is bidirectional due to local pressures. The length of Batson’s plexus is irrelevant to the question. B is incorrect
because Batson’s plexus, in general, does not have
valves or one-way movement of blood. Batson’s
plexus is located within the epidural space, not the
subarachnoid or subdural spaces.
GAS 102; N 169; McM 88
4