NBCE Part IV

When evaluating a lateral cervical spine radiograph, which anatomical landmark indicates the correct C1-C2 articulation?

• AThe anterior arch of C1 should align with the posterior third of the C2 vertebral body
• BThe anterior arch of C1 should align with the anterior third of the C2 dens
• CThe posterior arch of C1 should align with the spinous process of C2
• DThe lateral masses of C1 should overlap the C2 body by 50%

A 45-year-old patient presents with chronic lower back pain. AP lumbar radiographs reveal decreased disc space height at L4-L5 with osteophyte formation and subchondral sclerosis. What is the most likely diagnosis?

• ASpondylolisthesis
• BDegenerative disc disease with osteoarthritis
• CAnkylosing spondylitis
• DMetastatic disease

On a lateral lumbar radiograph, which finding is most consistent with spondylolysis?

• AAnterior wedging of the vertebral body
• BA radiolucent defect in the pars interarticularis
• CWidening of the intervertebral foramen
• DDecreased height of the intervertebral disc space

When interpreting a chest radiograph, which finding would be most concerning for metastatic disease to the lungs?

• AMultiple well-defined nodules of varying sizes throughout both lung fields
• BA single well-circumscribed nodule in the right upper lobe
• CBilateral hilar enlargement with perihilar infiltrates
• DApical pleural thickening with fibrotic changes

An AP full-spine radiograph of a 14-year-old patient reveals a right thoracic curvature measuring 28 degrees using the Cobb method. The curvature does not correct on lateral bending films. What is the most appropriate classification?

• APostural scoliosis
• BStructural adolescent idiopathic scoliosis
• CCongenital scoliosis
• DCompensatory scoliosis

On an AP pelvis radiograph, which finding is pathognomonic for Paget disease of bone?

• AMultiple well-defined lytic lesions with sclerotic borders
• BCortical thickening with bone enlargement and coarsened trabecular pattern
• CJoint space narrowing with subchondral cyst formation
• DUniform osteoporosis with cortical thinning

A lateral thoracic spine radiograph shows anterior wedging of T12 with approximately 25% loss of anterior vertebral body height. The endplates remain intact and no posterior element disruption is visible. What is the most appropriate classification?

• ACompression fracture, mild (Grade 1)
• BCompression fracture, moderate (Grade 2)
• CBurst fracture
• DChance fracture

Which radiographic finding is most characteristic of rheumatoid arthritis in the cervical spine?

• AFlowing ossification along the anterior vertebral bodies
• BErosive changes at the atlantoaxial articulation with potential basilar invagination
• CLarge osteophytes bridging multiple vertebral levels
• DVacuum phenomenon within the intervertebral discs

When evaluating scoliosis radiographs, what is the primary purpose of the Ferguson view (modified AP projection)?

• ATo visualize the spinal cord and neural elements
• BTo eliminate rotational distortion and visualize the true spinal curvature
• CTo assess spinal flexibility on lateral bending
• DTo visualize the posterior elements and pars interarticularis

An MRI of the lumbar spine demonstrates a focal, well-circumscribed lesion within the L3 vertebral body that is hyperintense on T2-weighted images and hypointense on T1-weighted images. The lesion shows peripheral enhancement after contrast administration. What is the most likely diagnosis?

• AVertebral hemangioma
• BSpinal metastasis
• CVertebral osteomyelitis with abscess formation
• DModic type 1 degenerative endplate change

On a lateral cervical radiograph, which measurement is used to assess for atlantoaxial instability?

• APowers ratio
• BAtlantodental interval (ADI)
• CSagittal vertical axis (SVA)
• DCobb angle

Radiographs of the knee reveal multiple enchondromas in the metaphyseal regions with expansion of the medullary cavity. The lesions show calcifications in a "rings and arcs" pattern. What is the most likely diagnosis?

• AOsteochondroma
• BEnchondromatosis (Ollier disease)
• CGiant cell tumor
• DChondrosarcoma

What is the primary advantage of CT imaging over conventional radiography for evaluating spinal trauma?

• ABetter visualization of bone marrow edema
• BSuperior soft tissue contrast for ligament evaluation
• CAbility to detect subtle fractures and assess spinal canal compromise
• DNo radiation exposure to the patient

On an AP lumbar radiograph, the left L5 pedicle appears enlarged and sclerotic compared to the right. The left neural foramen also appears widened. What is the most likely diagnosis?

• AOsteoid osteoma
• BOsteoblastoma
• CVertebral hemangioma
• DMetastatic disease

A lateral cervical spine radiograph demonstrates flowing ossification along the anterior aspect of at least four contiguous vertebral bodies with preservation of disc height. What is the most likely diagnosis?

• ADiffuse idiopathic skeletal hyperostosis (DISH)
• BAnkylosing spondylitis
• CSevere degenerative spondylosis
• DOssification of the posterior longitudinal ligament (OPLL)

Which finding on a bone scan would be most consistent with an acute vertebral compression fracture?

• AFocal photopenia (cold spot) in the affected vertebral body
• BDiffuse increased uptake throughout all visualized bones
• CFocal increased uptake (hot spot) in the affected vertebral body
• DNormal appearance without abnormal uptake

On AP and lateral lumbar radiographs, which finding indicates the presence of isthmic spondylolisthesis rather than degenerative spondylolisthesis?

• ADegenerative changes of the facet joints
• BA defect in the pars interarticularis with intact neural arch
• CNarrowing of the L4-L5 and L5-S1 disc spaces
• DOsteophyte formation along the vertebral endplates

A patient presents with back pain and fever. MRI demonstrates decreased T1 signal and increased T2 signal in the L4 and L5 vertebral bodies with loss of endplate definition at the L4-L5 disc space. What is the most likely diagnosis?

• AModic type 2 degenerative changes
• BVertebral osteomyelitis with discitis
• CMetastatic disease to the spine
• DSchmorl node formation

When measuring scoliosis using the Cobb method, which statement is correct?

• ALines are drawn along the endplates of the most tilted vertebrae at the apex of the curve
• BThe measurement is taken from the superior endplate of the uppermost vertebra to the infe…
• CLines are drawn perpendicular to the endplates of the most tilted vertebrae above and bel…
• DThe angle is measured between lines parallel to the vertebral bodies at the curve apex

On a chest radiograph, which finding is characteristic of a pneumothorax?

• AIncreased opacity with air bronchograms in the lung periphery
• BA visible visceral pleural line with absence of lung markings peripheral to it
• CEnlarged cardiac silhouette with bilateral pleural effusions
• DHyperinflated lung fields with flattened hemidiaphragms

A 35-year-old patient presents with acute low back pain following a lifting injury. During the history, the patient reports progressive weakness in both legs, urinary retention, and saddle anesthesia. What is the most appropriate immediate action?

• ASchedule a course of spinal manipulation and physical therapy
• BOrder outpatient lumbar MRI and follow up in one week
• CImmediate referral to emergency department for suspected cauda equina syndrome
• DPrescribe muscle relaxants and recommend bed rest for 48 hours

A 52-year-old patient with chronic neck pain presents with a new onset of severe headache, fever, and neck stiffness. The patient appears ill and has difficulty flexing the neck. What is the priority diagnostic consideration?

• ATension-type headache with cervical muscle spasm
• BMeningitis requiring immediate medical referral
• CCervicogenic headache from facet joint dysfunction
• DMigraine headache triggered by cervical spine pathology

During examination of a patient with shoulder pain, which finding would indicate a rotator cuff tear rather than subacromial impingement syndrome?

• APositive Neer impingement test
• BPositive empty can test with weakness on resisted abduction
• CPainful arc between 60-120 degrees of abduction
• DPain with Hawkins-Kennedy test

A 28-year-old patient presents after an ankle inversion injury. Examination reveals swelling over the lateral malleolus, tenderness over the posterior aspect of the fibula 6 cm proximal to the tip, and inability to bear weight for four steps. According to the Ottawa Ankle Rules, what is the appropriate management?

• AAnkle taping and return to activity with pain-limited restrictions
• BRadiographic series of the ankle and/or foot
• CConservative management with RICE protocol and follow-up in one week
• DImmediate MRI to evaluate for ligamentous injury

A 42-year-old patient presents with mid-thoracic back pain. History reveals a 20-pack-year smoking history, unexplained weight loss of 15 pounds over 3 months, and night pain that wakes the patient from sleep. What is the most appropriate next step?

• ABegin a trial of spinal manipulation therapy for mechanical thoracic pain
• BOrder thoracic spine radiographs to evaluate for possible malignancy
• CRecommend therapeutic exercises for postural dysfunction
• DPrescribe NSAIDs and schedule follow-up in 2 weeks

When obtaining informed consent for a cervical spine manipulation, which element is most essential to discuss with the patient?

• AThe exact number of vertebral levels that will be adjusted
• BPotential risks including vertebral artery dissection and stroke, along with benefits and…
• CThe specific HVLA thrust vector angle that will be used
• DDetailed biomechanics of cavitation and joint gapping

A patient with diabetes presents with a foot ulcer that has been present for 3 weeks. The wound is located on the plantar surface of the first metatarsal head, measures 2cm x 1.5cm, and probes to bone. There is surrounding erythema and purulent drainage. What is the priority management?

• ALocal wound care with topical antiseptic and off-loading
• BImmediate referral for diabetic foot infection with possible osteomyelitis
• CApplication of chiropractic adjusting to improve circulation
• DOral antibiotics prescribed by the chiropractor

During a cardiovascular examination, which finding would be most concerning for potential cardiac pathology?

• ASinus rhythm at 72 beats per minute with regular rate
• BA systolic murmur that decreases with Valsalva maneuver
• CAn irregularly irregular rhythm with no discernible P waves
• DA physiologic split S2 sound that widens on inspiration

A 55-year-old patient presents with new onset of severe, unrelenting low back pain. The patient has a history of prostate cancer treated 5 years ago. What is the most appropriate initial imaging study?

• ALumbar spine radiographs
• BMRI of the lumbar spine with and without contrast
• CCT scan of the lumbar spine without contrast
• DBone scan (scintigraphy)

A patient presents with elbow pain after a fall onto an outstretched hand. Examination reveals ecchymosis over the olecranon, significant swelling, and instability of the elbow joint with posterior prominence of the olecranon. What is the most likely diagnosis?

• ARadial head fracture
• BPosterior elbow dislocation
• COlecranon bursitis
• DLateral epicondylitis

A 38-year-old patient presents with acute onset of severe headache, described as "the worst headache of my life." The patient also reports nausea, photophobia, and neck stiffness. The patient is alert and oriented. What is the most appropriate management?

• ACervical spine manipulation to relieve muscle tension
• BPrescription analgesics and follow-up in 48 hours
• CImmediate referral to emergency department for evaluation of subarachnoid hemorrhage
• DSoft tissue therapy to the cervical musculature

When performing a neurological examination, which finding would indicate an upper motor neuron lesion?

• AFasciculations in the affected muscle groups
• BHyporeflexia or absent deep tendon reflexes
• CMuscle atrophy in the distribution of a peripheral nerve
• DHyperreflexia with clonus and positive Babinski sign

A 25-year-old patient presents with knee pain after playing soccer. Examination reveals a positive Lachman test with a soft endpoint. There is minimal effusion, and the patient reports feeling the knee "give way" during cutting movements. What is the most likely diagnosis?

• AMedial meniscus tear
• BAnterior cruciate ligament (ACL) tear
• CMedial collateral ligament (MCL) sprain
• DPatellofemoral pain syndrome

A patient with chronic low back pain is being evaluated. Which finding would be most indicative of non-organic (functional) pain?

• APain that worsens with forward flexion and improves with extension
• BPositive straight leg raise test at 30 degrees
• CSuperficial, non-anatomic tenderness and inconsistent motor weakness
• DDecreased sensation in an L5 dermatomal distribution

A 62-year-old patient presents with sudden onset of severe chest pain radiating to the back. The patient appears diaphoretic and anxious. Blood pressure is 180/110 mmHg in the right arm and 140/90 mmHg in the left arm. What is the priority action?

• APerform thoracic spinal manipulation to relieve musculoskeletal pain
• BOrder thoracic spine radiographs to evaluate for compression fracture
• CImmediate activation of emergency medical services for suspected aortic dissection
• DPrescribe analgesics and schedule follow-up with primary care physician

When documenting a patient encounter, which element is most essential for proper medical-legal protection and continuity of care?

• ADetailed description of the adjusting technique used
• BClear documentation of the clinical rationale for diagnosis and treatment, informed conse…
• CLengthy explanation of spinal subluxation theory
• DPatient's socioeconomic background and family history

A patient with hip pain has a positive FABER test (Patrick test). Which structure is most likely involved?

• AHip joint capsule and sacroiliac joint
• BIliotibial band
• CHamstring muscles
• DPatellofemoral joint

A patient presents with wrist pain after a fall onto an outstretched hand. Examination reveals tenderness in the anatomical snuffbox. Radiographs appear normal. What is the most appropriate management?

• AReassure the patient and resume normal activities
• BImmobilization in a thumb spica cast and follow-up imaging due to high suspicion for scap…
• CImmediate strengthening exercises for the wrist
• DApplication of heat and massage therapy

Which laboratory finding would be most consistent with active inflammation in a patient with suspected rheumatoid arthritis?

• ADecreased erythrocyte sedimentation rate (ESR)
• BNormal C-reactive protein (CRP)
• CElevated ESR and CRP
• DDecreased white blood cell count

When presenting a case to a medical colleague, which approach demonstrates professional communication standards?

• AFocusing exclusively on the spinal findings without discussing systemic concerns
• BUsing only chiropractic terminology without medical translation
• CProviding a concise summary with relevant history, examination findings, clinical impress…
• DDeferring all decision-making to the medical doctor without providing clinical input

When performing a diversified cervical spine manipulation, what is the primary purpose of pre-tensioning the joint to its elastic barrier?

• ATo ensure patient comfort during the procedure
• BTo localize the force and create joint surface separation before the thrust
• CTo increase the amplitude of the thrust
• DTo determine if manipulation is contraindicated

For a patient with an acute L5 facet syndrome presenting with painful limitation of left rotation and extension, which manual therapy approach would be most appropriate?

• AHigh-velocity low-amplitude thrust manipulation into the painful barrier of left rotation
• BFlexion-distraction technique with emphasis on extension
• CMobilization or manipulation that respects pain-free range and avoids aggravating positio…
• DAggressive muscle energy techniques forcing through the restrictive barrier

What is the primary contraindication to performing cervical spine manipulation?

• AHistory of previous cervical manipulation
• BAcute cervical strain without neurological signs
• CSuspected cervical arterial dysfunction or instability
• DChronic neck pain of greater than 6 months duration

When performing a side-posture lumbar manipulation, what is the purpose of rotating the upper body opposite to the pelvic rotation?

• ATo create traction on the lumbar spine
• BTo gap the intervertebral disc space
• CTo create rotation at the specific lumbar segment to be manipulated
• DTo relax the abdominal musculature

For a patient with a restricted sacroiliac joint on the right side (positive prone knee flexion test on the right), which manipulation setup would be most appropriate?

• ASide-posture with left side down, lumbar spine in flexion
• BSide-posture with right side down, drop table application to the sacrum
• CProne position with pelvic blocking using a wedge under the right ASIS
• DSupine position with straight leg raising manipulation

What is the recommended vector of thrust for a diversified cervical spine manipulation targeting the C5 segment with restricted right rotation?

• ADirectly posterior to anterior in the midline
• BPosterior to anterior, inferior, and toward the right (direction of restriction)
• CAnterior to posterior in a lateral direction
• DPurely rotational without linear component

When adjusting the thoracic spine in the prone position using a drop table, where should the contact point be placed for a T7 segmental restriction?

• ADirectly over the spinous process of T7
• BOver the lamina or transverse process of T7 with the line of drive perpendicular to the t…
• COn the rib angle at T7 with a lateral thrust
• DOver the inferior angle of the scapula