1. Osteology and Articulations of the Back 2008 Gray’s Pages 13-47

2. A 32-year-old male presents to the emergency room with the chief complaints of: nausea dizziness double vision limb numbness and weakness severe frontal and occipital headache. History reveals that these symptoms have become progressively worse over the past 6-months and become much more severe when he turns his head to the right. He was “treated” and released after an overnight stay. Three days later he presents to the emergency department with severe occipital headache, slurred speech, ataxic gait and lack of coordination. The admission CT was significant, showing multiple “brainstem” infarctions…

3. A 19-year-old female presents two days following an automobile accident. She indicates that she had a stiff neck that has since receded, but now she claims her neck feels “loose”. Physical exam reveals excessive rightward rotation of the head and atlas. What ligament has most likely been damaged?

4. A 22-year-old male presents with the main complaint of lower back pain that has progressively gotten worse over the past 6 weeks. Physical exam reveals: pain along L4 and L5 dermatomes weakness in the quadriceps hypo-reflexia at the patellar tendon tenderness to palpation along the lumbar spine An oblique radiograph of the lumbar spine reveals bilateral fractures of the pars interarticularis. What is the most likely diagnosis?

5. Superficial Back Gray’s Pages 47-54

6. An 18-year-old male presents following a mountain biking accident. History reveals he was thrown from the bike and landed on the side of his head (he was wearing a helmet). Physical exam reveals a fracture clavicle. On a follow-up visit, the fracture has healed but he has on the left: weakness in shrugging his shoulder, retracting the scapula and a decreased range of motion of the left upper extremity.

7. A 49-year-old male presents with the chief complaint of mass in his left side of two weeks duration. History reveals that he first felt the mass after painfully bending over to pick up a case of beer. Physical exam reveals a soft, non-tender mass in the mans back immediately below the tip of the 12 th rib on the left. No bowel sounds are heard over the mass.

8. Deep Back Gray’s Pages 54-62

9. A 35-year-old male presents with the main complaint of lower back discomfort. Physical exam reveals that L1 – L4 are SB L and R R. Dysfunction of what muscle is most likely responsible for this finding?

10. A 25-year-old female presents with the chief complaint of tightness in her neck and pain in the area indicated to the left.

11. 2008 Gross Anatomy 6: Spinal Cord and Meninges Gray’s Pages 63-69 Kulesza

12. A 18-year-old female presents with pain in her neck and in her right arm. Physical exam reveals pain along the lateral arm, involving the thumb. Grip strength is normal. Her upper limb reflexes on the right side are: biceps = 1/4 brachioradialis = 0/4 triceps = 2/4 What is the most likely etiology for these findings?

13. CLINICAL CONCEPT Muscle Strength is measured on a scale of 0 to 5. > Normal strength is 5/5 > Paralysis is 0/5 Muscle Stretch Reflexes are measure on a scale of 0 to 4. > Normal is 2/4 > PNS lesions are 0 or 1/4 > CNS lesions are 3 or 4/4

14. A 43-year-old female presents with abdominal pain of gradual onset. Physical exam reveals a non-tender, pulsating mass on the left side of the abdomen. An MRI and angiography reveals an aortic aneurysm. She elects for surgical repair. Physical exam following the surgery reveals on the left: a hypoactive patellar reflex [1/4] and weakness in the quadriceps [3/5]. What happened?

15. A 66-year-old male presents with the chief complaint of increased urinary frequency, back pain, lower limb weakness and numbness of two weeks duration. A digital rectal exam suggests prostate cancer. A gadolinium-enhanced MRI of the spine reveals:

16. A 12-year-old male presents with the chief complaint of fever, headaches, nuchal rigidity, nausea and lethargy of two days duration. History and physical exam leads to the suspicion of meningitis.

17. BACKGROUND An 87-year-old woman presents to the emergency department (ED) with acute onset of inability to move both of her legs over the past day. She had been hospitalized and discharged 2 weeks ago for a pulmonary embolism and at the time of discharge was feeling well and mobilizing independently. The patient reports mild progressive weakness of her lower limbs over the past 6 months with accompanying back pain. She states that she was able to walk and do her normal activities during that time without difficulty. She has a history of osteoporosis and had a radical nephrectomy for renal cell carcinoma 7 years ago. On physical examination, the patient appears well, though slightly cachectic. She has a pulse of 90 bpm, a blood pressure of 130/90 mm Hg, and a temperature of 97.7°F (36.5°C). The cardiac and pulmonary examinations are unremarkable, with a regular rhythm and no increased work of breathing. She has a soft abdomen with no rebound or tenderness to palpation. There is evidence of a well-healed scar from her previous nephrectomy. Muscle strength globally in her lower limbs is 0 in the right leg and a 2 in the left leg. Pain and temperature sensation is absent throughout the lower limbs. There is slightly decreased rectal tone. The remainder of her physical examination is unremarkable. A magnetic resonance imaging (MRI) scan of the thoraco-lumbar spine is performed (see Images 1 and 2).

18. What is the diagnosis?