Dental MCQ
Tract anatomy and crossings · Neuroanatomy · INBDE Patient Cases

Spinal Pathways INBDE Patient Cases

By Dr. Isaac Sun, DDS

8 ADA INBDE-format patient cases on spinal pathways. Each case is a shared patient box (chief complaint, history, medications, allergies, exam) followed by linked multiple-choice questions with full distractor explanations. Practice the way the real exam is structured.

8 patient cases40 linked questionsADA INBDE formatFull distractor explanations

Eight ADA INBDE-format patient cases on spinal cord pathways and the neurological conditions a dentist manages: the corticospinal tract, dorsal columns, spinothalamic tract, anterior horn, and cervical cord. Topics include atlantoaxial instability and neutral-neck positioning in Down syndrome, traumatic central cord syndrome from a chin-strike fall, vitamin B12 subacute combined degeneration with atrophic glossitis, multiple sclerosis with Lhermitte's sign and trigeminal neuralgia, amyotrophic lateral sclerosis with tongue fasciculations and aspiration risk, dental care and adaptive hygiene for a wheelchair user with a spinal cord injury, autonomic dysreflexia during dental treatment, and latex precautions in spina bifida.

Case Coverage Map
What each case is testing
Planning sedation for a teen with Down syndrome:
Atlantoaxial instability, neutral-neck positioning, myelopathy warning signs, Down oral findings.
Arm-predominant weakness after a chin-strike fall:
Traumatic central cord syndrome, corticospinal somatotopy, cervical injury from facial trauma.
Numb feet, smooth sore tongue, unsteady gait:
B12 subacute combined degeneration, dorsal columns + corticospinal, atrophic glossitis, PPI link.
Electric shocks down the spine and facial pain:
Multiple sclerosis, Lhermitte's sign, MS-related trigeminal neuralgia red flags.
Hand weakness with a twitching, wasting tongue:
ALS, mixed upper/lower motor neuron signs with spared sensation, bulbar aspiration risk.
Routine care for a wheelchair user with a cord injury:
Adaptive oral hygiene, anticholinergic xerostomia, safe transfer, dysreflexia awareness above T6.
Headache and blood-pressure spike in an SCI patient:
Autonomic dysreflexia, full-bladder trigger, sit-up-and-relieve management, baroreflex bradycardia.
Dental care for a young adult with spina bifida:
Latex-free environment, neural tube defect, neurogenic-bladder xerostomia, anaphylaxis response.
Patient case: Planning sedation for a teen with Down syndrome
0 of 5 answered, 0 correct
Patient
Male, 16 years old with Down syndrome, with his mother
Chief Complaint
Mother: "He needs several fillings, and his last dentist mentioned checking his neck before sedation."
Background and/or Patient History
  • Down syndrome (trisomy 21) with generalized ligamentous laxity
  • Multiple carious teeth; limited cooperation, sedation likely
  • No current neck pain, weakness, or change in gait
  • Generalized gingival inflammation and delayed exfoliation
Allergies
NKDA
Medications
  • None
Current Findings
  • Macroglossia and fissured tongue
  • Generalized gingivitis
  • No focal neurologic deficit on screening
  1. Question 1
    Moderate
    Why does his neck position matter for cord safety during treatment?
  2. Question 2
    Moderate
    Which symptoms would suggest cervical myelopathy and warrant evaluation first?
  3. Question 3
    Moderate
    The safest positioning approach for him is to:
  4. Question 4
    Moderate
    Which oral findings are common in Down syndrome and affect his care?
  5. Question 5
    Moderate
    Before sedation, the most appropriate step regarding his neck is to:

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Patient case: Arm-predominant weakness after a forward fall
0 of 5 answered, 0 correct
Patient
Male, 72 years old
Chief Complaint
"After I tripped and hit my chin, my hands and arms are weak and burning, but my legs are working much better."
Background and/or Patient History
  • Forward fall with neck hyperextension, striking the chin (note the chin laceration relevant to dental trauma)
  • Known cervical spondylosis
  • Weakness and burning dysesthesia worse in the upper extremities than the lower
  • No penetrating injury
Allergies
NKDA
Medications
  • Lisinopril 10 mg daily
Current Findings
  • Upper-extremity weakness greater than lower-extremity weakness
  • Cape-like burning sensory changes over the arms
  • Chin laceration and dentoalveolar trauma from the fall
  1. Question 1
    Moderate
    This injury pattern (arms weaker than legs after a hyperextension fall) is:
  2. Question 2
    Hard
    The crossing fibers most affected at the center of the cord are the:
  3. Question 3
    Hard
    Why are the upper extremities weaker than the lower in central cord syndrome?
  4. Question 4
    Moderate
    The chin laceration and broken teeth from the fall are clinically important because:
  5. Question 5
    Moderate
    Central cord syndrome differs from a complete cord transection in that it:

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Patient case: Numb feet, a sore smooth tongue, and an unsteady gait
0 of 5 answered, 0 correct
Patient
Female, 63 years old
Chief Complaint
"My feet feel like pins and needles, my tongue is sore and smooth, and I feel unsteady, especially in the dark."
Background and/or Patient History
  • Longstanding pernicious anemia (autoimmune, low vitamin B12)
  • Progressive numbness and tingling in the feet and hands
  • Unsteady gait, worse with eyes closed
  • Recently noted a smooth, burning tongue
Allergies
NKDA
Medications
  • Omeprazole (long-term)
  • Levothyroxine
Current Findings
  • Loss of vibration and proprioception in the feet (dorsal columns)
  • Brisk reflexes and an extensor plantar response (corticospinal involvement)
  • Atrophic glossitis: a smooth, red, sore tongue
  • Positive Romberg sign
  1. Question 1
    Moderate
    Which spinal cord tracts are degenerating in this B12 deficiency?
  2. Question 2
    Moderate
    Her positive Romberg sign indicates loss of:
  3. Question 3
    Moderate
    Her smooth, sore tongue (atrophic glossitis) is a recognized oral sign of:
  4. Question 4
    Hard
    Which of her medications can contribute to B12 deficiency over time?
  5. Question 5
    Easy
    If untreated, the most important consequence of recognizing this early is that:

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Patient case: Electric shocks down the spine and facial pain in a young woman
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Patient
Female, 32 years old
Chief Complaint
"When I bend my neck I get an electric shock down my spine, and I keep getting jolts of facial pain on both sides."
Background and/or Patient History
  • Two prior episodes of transient limb numbness and an episode of optic neuritis (painful vision loss) that resolved
  • Symptoms separated in time and location
  • Electric sensation down the spine on neck flexion (Lhermitte's sign)
  • Recurrent lancinating facial pain, at times bilateral
Allergies
NKDA
Medications
  • None currently
Current Findings
  • Lhermitte's sign on neck flexion (dorsal column irritation)
  • Variable, asymmetric sensory and motor findings
  • Trigeminal neuralgia-type facial pain, notable for being bilateral and young-onset
  1. Question 1
    Moderate
    Her history of deficits separated in time and space most suggests:
  2. Question 2
    Hard
    Lhermitte's sign (an electric shock down the spine on neck flexion) reflects irritation of the:
  3. Question 3
    Moderate
    Her bilateral facial pain in a young patient is a recognized association of MS as:
  4. Question 4
    Moderate
    Why is trigeminal neuralgia that is bilateral or occurs in a young patient a red flag?
  5. Question 5
    Hard
    A practical chairside point when treating a patient with MS-related trigeminal neuralgia is to:

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Patient case: Hand weakness with a twitching, wasting tongue
0 of 5 answered, 0 correct
Patient
Male, 58 years old
Chief Complaint
"My hands are getting weak and clumsy, my speech is slurred, and my tongue twitches and seems to be shrinking."
Background and/or Patient History
  • Progressive painless weakness over a year
  • Both stiffness (spasticity) and wasting with twitching (fasciculations)
  • Increasing dysarthria and difficulty swallowing
  • No sensory loss and no bowel or bladder problems
Allergies
NKDA
Medications
  • Riluzole
Current Findings
  • Mixed signs: brisk reflexes and spasticity (upper motor neuron) with muscle wasting and fasciculations (lower motor neuron)
  • Tongue atrophy with visible fasciculations; dysarthria and dysphagia (bulbar signs)
  • Sensation entirely intact
  1. Question 1
    Moderate
    The combination of upper and lower motor neuron signs with no sensory loss is characteristic of:
  2. Question 2
    Moderate
    His brisk reflexes with spasticity indicate involvement of the:
  3. Question 3
    Moderate
    His tongue wasting and fasciculations are signs of:
  4. Question 4
    Hard
    His dysphagia and impaired tongue and pharyngeal control create the dental risk of:
  5. Question 5
    Moderate
    Which finding argues against ALS and should make you reconsider the diagnosis?

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Patient case: Routine care for a wheelchair user with a spinal cord injury
0 of 5 answered, 0 correct
Patient
Male, 41 years old, uses a wheelchair
Chief Complaint
"I have a spinal cord injury and I'm here for a checkup; my hands don't work well enough to floss."
Background and/or Patient History
  • Complete thoracic spinal cord injury several years ago (paraplegia)
  • Limited hand function for brushing and flossing
  • Generalized plaque and gingival inflammation
  • Transfers from the wheelchair with assistance
Allergies
NKDA
Medications
  • Baclofen
  • An anticholinergic for bladder control
Current Findings
  • Heavy plaque with gingival inflammation
  • Dry mouth (bladder anticholinergic)
  • Requires assisted transfer and careful positioning
  1. Question 1
    Easy
    His impaired hand function most directly affects:
  2. Question 2
    Easy
    The most useful oral-hygiene aids for him are:
  3. Question 3
    Moderate
    His bladder anticholinergic medication contributes to his oral disease by causing:
  4. Question 4
    Moderate
    During transfer and positioning, an important precaution is to:
  5. Question 5
    Hard
    If his injury were above T6, which additional emergency should you guard against?

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Patient case: Pounding headache and a blood pressure spike in a patient with a spinal cord injury
0 of 5 answered, 0 correct
Patient
Male, 38 years old
Chief Complaint
During a long restorative appointment he says, "I have a pounding headache and I feel flushed and sweaty above my chest."
Background and/or Patient History
  • Complete spinal cord injury at C6 three years ago (tetraplegia)
  • Long appointment; has not been catheterized and the bladder is full
  • Sudden pounding headache, facial flushing, and sweating above the lesion
  • He recognizes the symptoms as a prior episode
Allergies
NKDA
Medications
  • Baclofen
  • Oxybutynin
Current Findings
  • Severe hypertension (systolic far above his baseline)
  • Reflex bradycardia
  • Flushing and sweating above the level of injury; pallor and goosebumps below
  1. Question 1
    Moderate
    This emergency is:
  2. Question 2
    Moderate
    The most common triggering stimulus is:
  3. Question 3
    Hard
    The first management steps are to:
  4. Question 4
    Hard
    Why is the bradycardia present despite the high blood pressure?
  5. Question 5
    Moderate
    To reduce the risk of this happening at future visits, you should:

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Patient case: Dental care for a young adult with spina bifida
0 of 5 answered, 0 correct
Patient
Female, 20 years old with spina bifida, uses a wheelchair
Chief Complaint
"I'm here for a cleaning; my chart says I have a serious latex allergy."
Background and/or Patient History
  • Spina bifida (myelomeningocele) with a repaired lower spinal defect
  • Lower-limb weakness and a neurogenic bladder (intermittent catheterization)
  • Documented severe latex allergy
  • Has a ventriculoperitoneal shunt for hydrocephalus
Allergies
Latex (severe)
Medications
  • Oxybutynin
  • Baclofen
Current Findings
  • Lower-extremity weakness; uses a wheelchair
  • Neurogenic bladder managed by catheterization
  • Documented latex sensitivity
  1. Question 1
    Moderate
    The single most important environmental precaution for her visit is:
  2. Question 2
    Hard
    Why are patients with spina bifida at high risk for latex allergy?
  3. Question 3
    Moderate
    Spina bifida results from a failure of:
  4. Question 4
    Moderate
    Her oxybutynin for the neurogenic bladder affects oral health by causing:
  5. Question 5
    Moderate
    If she developed hives, wheezing, and a falling blood pressure during care, you should:

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Spinal Pathways core recall

Refresh the anatomy facts these cases depend on: nerve numbers, foramina, functions, and lesion findings.

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