Radiology Spine

Question 1

Ankylosing spondylitis

Answer 1

spondyloarthropathy. chronic, multisystem inflm disorder primarily in sacroiliac joints (SI) and axial skeleton. HLA-B27
clinical presentation:
1) insidious onset of low back pain and stiffness
2) spontaneous remision and exacerbation
3) onset sx< 40yo
4) present sx >3mo
5) sx worse in morning or with inactivity
6) improve after exercise

Question 2

skeletal ankylosing spondylitis

Answer 2

sacroilitis and spondylitis. spondylodiscitis, enthesitis, arthritis of hips and shoulder. osteoporosis and vertebral fractures, pseudoarthrosis

Question 3

extraskeletal ankylosing spondylitis

Answer 3

anterior uveitis, enteric mucosal lesions, lungs, incr CVD, atlantoaxial J subluxation and SC compression, cauda equina syndrome, IgA nephropathy and amyloidosis

Question 4

ankylosing spondylitis dx

Answer 4

bamboo spine due to vertebral fusion by marginal syndesmophwytes. MRI or CT of Si J, spin, peripheral J may reveal early sacroilitis erosions.

Question 5

ankylosing spondylitis tx

Answer 5

symtomatic: pain ctrl with NSAIDs, selective COX2, DMARDs, anti-TNF inhibitor, pamidronate, thalidomide, exercise, physical therapy. surgical- stability fracture and prevent neuro deficit

Question 6

ASA infarction presentation

Answer 6

acute motor paralysis (usually bilateral), loss of complete P/T. sparing of proprioception nd vibratory. hypotension, sexual dysfunction or bowel and bladder dysfunction, compromise respiration if lesion is in rostral cervical cord

Question 7

ASA infarct neuro exam

Answer 7

vary with portion of cord affected. deficit below lvl of lesion. LMN sign, UMN sings. lower extremity affected more than upper. bilateral P/T loss.

Question 8

asa infarction radiology

Answer 8

restricted diffusion on DWI. abn signal in vertebral body. min enhancement unlike spinal tumor. snake eye appearance of corticospinal tracts

Question 9

ASA infarction tx

Answer 9

sx care of bladder, bowel, skin. maybe high dose corticosteroid or anticoag

Question 10

anterior horn cellitis

Answer 10

MRI show swelling of T2 - owl’s eyes bc involve central gray matter. bilateral LE weakness and areflexia

Question 11

B12 myelopathy

Answer 11

-neuro dysfunc in peripheral and optic N, posteiror and lateral columns of SC. Present with cold numbness, tingling in tips of toes and then fingers- ascending paresthesias. limb weakness and ataxia if untx.
neuro exam: impair vibration and J-position sense with progresses over time to loss of light touch, pin-prick, and T. leg affected bf arm. positive romberg. absent ankle jerk with relative hyperreflexia at knees. dx: MRI spine may reveal T2/FLAIR hyper intensity in posterior column. tx: parenteral or oral cobalamin

Question 12

HIV vacuolar myelopathy

Answer 12

late stages of HIV, low CD4, vacuolation of lateral and posterior columns. resemble myelopathy of B12 def.
Clinical: gradual progression of painless leg weakness, stiffness, sensory loss, imbalance, sphincter dysfunction
neuro: slowly progressive spastic paraparesis with rare involvement of upper extremities, hypereflexia, pos babinski, sensory ataxia, bladder and bowel incontinence.
dx studies: T2 weighted MRI- symmetric non-enhancing hyperintesnsities, tx: supportive care- anti spasticity agent, manage sphincter dysfunc , rehab

Question 13

spinal AVM

Answer 13

dural, intradural or intrameddular. dev in embryogenesis.
present: progressive back pain, sensory loss, weakness over mo-y. if hemorrhage- acute severe back pain, weakness, or paralysis. numbness with discrete sensory lvl. urinary/fecal incontinence.
neuro exam: bruit over SC. UMN signs, spastic paraparesis or quadriparesis, loss of P/T caudal to lesion
imaging: MRI = first line. digital subtraction angiography is gol standard.
tx: surgical ligation or resection, endovascular emboliation, spinal radiation, or combo

Question 14

spinal cavernomas cause and clinical presentation

Answer 14

sinusoidal vascular channels lined with endothelium, surrounded by hemosiderin stained glotic rim of tissue. rare

clical:
1) progressive-slow dev of chronic myelopathy due to micohemorrhages or enlarged cavernoma –> mass effect.
2) acute- in hemorrhage, severe back pain, weakness or paralysis, numbeness, hyperreflexa, urinary/fecal incontinence.
3) episodic: hemorrhage resolves and rebleed occur.

Question 15

SC cavernous malformtation (SCCMs) neuro exam, imaging, tx

Answer 15

neuro: incr tone and hyperreflexia caudal to lesion, spastic paraparesis or quadriparesis base on location .sensory and t loss caudal.
imaging: popcorn -gradient echo.
tx: resction

Question 16

episdural metastasis

Answer 16

mostly from breast, lung or prostate ca. SC compression most often at thoracic lvl. clinical presentation- pain- progressive racial referred or radicular. later with myelopathy
neuro exam: spastic paraparesis, loss of sensation to all modalities, UPM signs, loss of rectal sphincter tone.
dx: MRI, leptomeningeal enhancement and intramedulary tumor. if unknown primary lesion then biopsy.
tx: high dose IV corticosteroids, radiotherapy, decompressive surgery

Question 17

nerve sheath tumor

Answer 17

25% of tumor arising in intradural, extra medullary space. ex schwannomas
Etiology: sporatic (50s-70s( or inherited - NF1 or NF2
patho: derive from schwann cells or perineurial cell soft PNS.
clinical presentaiton: slow growing. often simp, can cause back or radicular pain. worse at night or in morning,resolve during day.
neuro: spastic paraparesis, diminished sensory below lesion, UMN signs, loss of bowel/bladder sphincter tone.
dx: MRI spine+ gado. majority enhance diffusely. heterogenous enhancement if intramural cyst or necrosis present
tx: gross total resection- goldstanard. no chemo/rad

Question 18

syringomyelia: etiology, presenation

Answer 18

fluid filled cavity within SC
etiology: chiari I or II. tethered cords (congital or acquired), spinal archnoiditis, trauma, SC tumor, VP shunt, idiopathic
clinical presentation: dissociated sensory loss: no P/T. has light touch, proprioception, vibratory sensation. often cape like distribution over shoulder and back. pain frequently felt in neck and shoulders. as central lesion enlarge, weakness in more distal M follow by proximal, an atrophic areflexic paralysis dev due to disruption of centrally situated anterior horn GM. bladder dysfunc and urinary retention

Question 19

syringomyelia neuro exam, dx, tx

Answer 19

neuro: cape - lose P/T. motor: UMN- bilateral motor paresis, upper?lower. LMN- atrophic, arefexic paralysis at site of lesion
dx: MRI spine show dilated cavity with same intensity as CSF on T2. no gad.
tx: vary based on etiology.

Question 20

syringobulbia

Answer 20

syrinx rupture –> brainstem. cause direct entry of CSF into brainstem
clinical: early sign and sx of CN 10-12- dysphonia, dysarthria, dysphagia, palatal and tongue weakness. pt also complain of HA, vertigo, diplopia, tinnitus.
Neurology exam: CN def, nystagmus, weakness, hyperreflexia, scoliosis,
tx: surgical with sub occipital craniotomy or craniovertebral decompression. monitor for hydrocephalus prior to surgery

Question 21

syringobulbia

Answer 21

when syrinx rupture extends into brainstem causing direct entry of CSF into brainstem

Question 22

syringobulbia clinic

Answer 22

early: lower cranial N dysfunc (10-12)- dysphonia, dysarthria, dysphagia, palatal and tongue weakness. sometimes HA, vertigo diplopia, tinnitus
neuro exam: CN deficit, nystagmus, weakness, hyperreflexia, scoliosis

Question 23

syringobulbia tx

Answer 23

surgical-suboccipital craniotomy or craniovertebral decompression. monitor for hydrocephalus prior to surgery

Question 24

cervical spondylotic myelopathy (CSM) clinical

Answer 24

most common SC D in elderly (>55). clinical: insidious onset of neck, sub scapular, should pain radiating to arm uni or bilateral. clumsy, weak, numb, or tingling hands. weak or stiff leg. stiff neck. gait prob. bladder dysfunc.

Question 25

CSM neuro exam

Answer 25

Motor: weakness or atrophy of UE. LMN finding in myotomal distribution. abysm lower extremity weakness and spasticity (UMN findings) sensory: variable, asym. dermatomal or sensory lvl reflexes: hyperreflexia, ankle clonus, babinski sign, hoffman's sign gait- spastic, scissoring quality, lhermitt'e sign: electric shock like sensation down center of back following neck flexion

Question 26

CSM dx, tx

Answer 26

MRI or CT. tx: surgical- decompression of SC when frank myelopathy occurs. med- noninvasive therapy- cervical immobilization (color or neck brace), cervical traction, skull traction and physical therapy

Question 27

cervical spondylitic myelopathy path

Answer 27

path: antibody to aqauporin 4 (NMO IgG) ch in capillaries of brainstem and cerebellum

Question 28

cervical spondylitic myelopathy presenation

Answer 28

sx of para or quadiplegia, sensory loss and sphincter paralysis (acute myelitis) and visual loss (optic neuritis)

Question 29

cervical spondylitic myelopathy neuro exam + dx

Answer 29

neuro: persistent and profound flaccidity of legs (arms if cervical lesion), areflexia, atonality of bladder CSF analysis: few-100s of mononuclear cell. incr protein, no oligoclonal bands imaging: MRI-T2 signal changes and gado enhancement of cord. cord swelling may be present in acute to subacute period. longitudinally extensive lesion that occupy several spinal seg. atrophy of involved set of cord

Question 30

cervical spondylitic myelopathy tx

Answer 30

high dose corticosteroid, plasma exchange to remove NMO ab, cyclophosphamide to prevent relapses

Question 31

spinal neurocysticercosis, patho, presenation

Answer 31

rare. seed in subarachnoid space. present: asym. if grow, compress SC- late insidious onset of black/radicular pain with progressive weakness and myelopathy

Question 32

spinal neurocysticercosis neuro exam +dx

Answer 32

motor- spastic paraparesis sensory- sensory lvl- decr sensation below lesion reflexes- hyperreflexic, toes upgoing bowel, bladder: loss of sphincter tone T1- cyst wall is isointense to CSF T2- incr signal intesnisty in cyst. pericystic edema in SC parenchyma. occasionally scolex visualized as a mural nodule

Question 33

spinal neurocysticercosis tx

Answer 33

praziquantel or albendazole and steroids. surgical decompression and excision of lesions in setting of clinical deterioration

Question 34

demyelinating disease of the spine presentation

Answer 34

presentation: numbness that spreads over 1 or both sides of the body from sacral set to ft, anterior thighs and up over trunk. variable and usually asx weakness and then paralysis of the legs. -sphincter dysfunc- late complication

Question 35

demyelinating disease of spine dx, tx

Answer 35

CSF- mild or normal lymphocytosis. oligoclonal bands (sometimes absent on 1st attack) MRI T2- abn. gado enchancement. w/wo cord expansion tx: high dose corticosteroid, plasma exchange, IVIG

Question 36

cauda equina syndrome (CES) caused by...

Answer 36

mass from conus modulars or film terminal consistent with ependymoma narrowing of SC that compress N root below termination of SC.

Question 37

CES present

Answer 37

localized low back pain w/wo unilateral or bilateral sciatica (radicular pain); pain may be completely absent -bowel and bladder dysfunc (urinary manifestation begin with retention then overflow incontinence) constipation weakness of legs saddle anesthesia sexual dysfunc- impotence (less common)

Question 38

CES neuro exam

Answer 38

motor- asym paraplegia, hypotonia, rare fasiculations, atrophy with chronic lesions sensory- saddle hypoesthesia or anesthesia, lower extremity sensory loss is asx (may be unilateral) in specific dermatomes; no sensory dissociation reflexes- absent or diminished knee or ankle jerks and diminished bulbocavernous reflex loss of anal sphincter tone and anal wink

Question 39

CES dx

Answer 39

L spin with gad. EDX- EMG of lower extremities and bilateral external anal sphincter M- acute denervation; NCS of pudendal N may rule out more distal peripheral nerve lesions lumbar puncture- r/o inflm diseases

Question 40

CES tx

Answer 40

urgent surgical decompression in <6hr from injury medical therapy- antibiotics for infection, steroids for inflm conditions. no proven medical tx, direct at cause PT, OT

Question 41

spinal lipoma patho, etio

Answer 41

intradural fatty accumulation. mostly in T-spine in adult and C-spine in kids. dorsal midline of SC--> flatten cord ventrally 20s-30s

Question 42

spinal lipoma presentation

Answer 42

slow growing, mass effect. numbness or spastic weakness in extremities, back pain, radicular pain uncommon

Question 43

spinal lipoma neuro exam

Answer 43

motor- splastic paraparesis sensory- sensory lvl with decr sensation below lesion reflexes- hyperreflexic toes upgoing bowel/bladder- loss of sphincter tone

Question 44

neuroimaging spinal lipoma

Answer 44

CT- homogenous low attenuation, wo solid of enhancing component MRI- sharply circumscribed mass largely conform to dura but distorting cord. follow fat signal on all seq. t1-hyper, T2-hypo, no enhancement on T1 post

Question 45

spinal lipoma tx

Answer 45

decompression with biopsy or subtotal resection

Question 46

pott's spine.

Answer 46

osteomyelitis +arthritis. usually affect >1 vertebra. 85%- in thoracolumbar. etio- 2nd to extraspinal source --> progressive bone destruction leading to anterior vertebral body collapse and kyphosis (gibbous deformity), cold abscess formation, SC narrowing (by abscesses, granulation tissue, direct dural invasion), leading to SC compression and neuro deficits

Question 47

pott's clinical

Answer 47

varies based on stage, site affected, presence of complications (neuro deficit, abscess or sinus tracts) - constitutional sx (fever, wt loss, night sweat) - spinal or radicular back pain (earliest and most common sx) - rare dysphagic, stridor, torticollis, hoarseness (due to lower cervical spine disease) - focal weakness and sensory abn - bladder and bowel dysfunction

Question 48

potts disease neuro exam

Answer 48

varies based on lvl of SC or nerve root compression - kyphosis deformity -local pain in affected are of spine associated with muscle spasm and rigidity motor- progressive para/quadriparesis sensory- impaired sensation below lvl of lesion reflexes- hyperreflexia with ankle clonus and upping toes

Question 49

pott's dx

Answer 49

lab- ppd, ESR, microbiology imaging- MRI with gad- evaluate disk space infection and osteomyelitis.. demonstrate extension of disease into soft tissue and spread of TB debris under anterior and posterior longitudinal ligaments. CT- define shape and calcification of soft tissue abscesses histo- exudative granulation tissue with interspersed abscesses --> caveating necrosis

Question 50

pott's tx

Answer 50

RIPE. 6-12mo. decompressive surgery if acute neuro deterioration, spinal deformity with instability, R to drug, paravertebral abscess or non-diagnostic bx

Question 51

spinal cord contusion- patho

Answer 51

most common cord injury. bruised cord --> inflm, bleeding from vessels. temporary -1-2d incomplete or complete debilitation of SC

Question 52

spinal cord contusion presentation

Answer 52

varying degree of sx associated with location and severity. | weakness, numbness, tingling below lesion, bladder and bowel dysfunc

Question 53

spinal cord contusion neuro exam

Answer 53

varies with level and portion of cord affected. deficit below lvl of lesion LMN- acutely due to spinal shock- flaccid paraparesis or quadriparesis UMN- over d-wks. spastic paraparesis or quadriparesis sensory decr. loss of anal sphincter tone

Question 54

spinal cord contusion dx, tx

Answer 54

mri- T2/FLAIR signal change- cord edema tx- supportive care, spine immobilization, collar or brace, high dose corticosteroid, mechanical ventilation, bladder catheter, feeding tube, physical therapy

Question 55

spinal meningiomas etio, path

Answer 55

most common intramural, extra medullary tumor. 25-46% of primary spinal neoplasm. 4:1 W/M. middle age. 80% in T spine, 15% c spine, arise from arachnoid cap cells of arachnoid villi in meninges

Question 56

spinal meningiomas- present

Answer 56

slow growing tumor, often asx. if big --> back or radicular pain --> weakness+/- sensory change with sphincter disturbance- late finding

Question 57

spinal meningiomas neuro exam, dx

Answer 57

``` motor- spastic paraparesis sensory- sensory lvl decr below lesion reflex- UMN loss of sphincter tone MRI spine with gad- isodense to spinal cord on T1 and T2 with intense enhancement post contrast ```

Question 58

spinal meningioma tx

Answer 58

high dose corticosteroid if SC compression, surgical resection + rad if malig=rare

Question 59

neuroenteric cyst, etio, patho

Answer 59

rare lesion of SC. heterotypic endodermal tissue. 90% in intramural/extramedullary. etio- persistence of neuroenteric canal prevent proper sep of endoderm and notochord --> congenital cyst define by presence of mucus secreting epithelium ~ GI tract

Question 60

neuroenteric cyst clinical

Answer 60

progressive focal pain at lvl of lesion, radicular pain and paresthesias, fluctuating myelopathic signs bladder and bowel dysfunc - based on location

Question 61

neuro enteric cyst neuro exam

Answer 61

motor- fluctuating unilateral or bilateral spastic paraparesis/ quariparesis sensory- sensory lvl may be present reflexes- fluctuating UMN

Question 62

neuroenteric cyst imaing

Answer 62

MRI + gado- delineate cyst form and relationship to surrounding neural structures non contrast enhacing lesion that are isoentense on T1 and hyper on T2 CT- detect osseous malformation CT myelogram- positive meniscus sign (partial dye obstruction with intramural/extramedullary cyst and complete contrast obstruction with intramural/intramedullary cyst

Question 63

neuroenteric cyst tx

Answer 63

surgery-total resection. partial-> recur+ arachnoiditis

Question 64

cervical disk herniation, patho, presentation, dx, tx

Answer 64

radiculopathy- mechanical compression or irritation of N as it exist spine. most in C/L spine due to motility of neck and lower back causes- disk herniation, osteophyte from osteoarthritis, thickening of surrounding lig numbness, tingling, weakness, M atrophy. decr reflexes.local or radicular pain dx: MRI or CT spine. EDX - to determine exact root involved tx- bed rest, PT, NSAIDS, M relaxants. steroid for severe pain surgery if refractory to medical management

Question 65

copper deficiency myelopathy | etio, presnt, neuro, dx, tx

Answer 65

acquired, non-compressive myelopathy. mimic subacute deign due to it B12 def. etio- impair absorption- gastric surgery, zinc overload, malabsorption syndrome present- progressive spastic ataciv gait with proprioceptive deficits due to polyneuropathy neuro: UMN, sensory ataxia due to impaired vibration and J-position sense, pos romberg, wide based ataxic and spastic gait dx- MRI T2 hyper in dorsal midline C or T spine low serum copper and ceruloplasmin lvl tx- copper supplement

Question 66

spinal epidural hematoma (SEDH) patho

Answer 66

usually in thoracolumbar. peridural venous plexus > arterial sources. expansion limited to few vertebrae lvl

Question 67

SEDH presentation

Answer 67

sudden, severe focal neck or back pain with delayed radicular pain. weakness, numbness, tingling below lvl of lesion. bladder and/or bowel dysfunc. Neuro: LMN acutely (spinal shock) --> UMN para or qudriparesis. sensory lvl with radicular paresthesias.

Question 68

SEDH dx, tx

Answer 68

dx- MRI- location/extent. show biconvex. taper superior and inferiorly functional study SSEP use for monitor or prognostication following surgery tx- surgical intervesion 36-48hr with decompressive laminectomy and hematoma removal conservative tx when neuro deficit improve in early phase or with coexistence of coagulopathy

Question 69

spinal epidural abscess (SEA)

Answer 69

infection what spread over verbal lvl and expand threatening SC or cauda equine directly by mechanical compression and indirectly by vascular compromise. most in T spine taph aureas- most common

Question 70

SEA present

Answer 70

triad- fever, back pain, neuro deficit stage 1) focal pain at level 2) radicular pain + paresthesias, 3) M/S/ B/B dysfunc 4) paralysis neuro- tenderness to palpation. LMN acute --> UMN. senosry lvl with radicular paresthesias.

Question 71

SEA dx, tx

Answer 71

lab- culture, CBC, ESR, leukocytosis in 2/3 pt. MRI with gado, LP- CI if suspect unless need to exclude meningitis tx- emergency decompression + drainage. antibiotic against MRSA. penicillin, 3rd gen cephalosporin, amino glycoside.

Question 72

alantoaxial instability (AAI)

Answer 72

excessive mvt at junction btw C1, C2 due to bony or ligamentous abn. occipital pain, vertigo, brainstem sign, lower CN palsy, myelopathy. sudeck sign- displacement of spine of axis in direction of head tilt plain radiograph or CT no tx for asx, cervical stabilization if sx

Question 73

synovial cyst

Answer 73

facet J dty causing degeneration or herniation of synovial fluid through tears in J capsule most at L4/5 due to mobility causing spinal instability. presentation dep on size, site, relationship to adj structures. most radicular or back pain, neurogenic claudication, or caudal equip syndrome. myelopathy if C/T spine neuro mild weakness to myelopathy (UMN) hypo on T1, hyper T2 tx: conservative -bred rest, NSAID, PT, bracing, transcutaneous electrical stimulation, epidural or intra-articular steroid injection and cyst aspiration surgical- facetectomy with laminectomy

Question 74

burst fracture

Answer 74

14% of spinal injury. in high energy trauma. most in thoracolumbar J. present with moderate to severe back pain exacerbated by mvt. numbness, tingling, weakness. B/B dysfunc if SC involved. CT > plain raiography MRI- soft tissue injury tx- conservative management with brace and pain management if no neuro deficit. decompression, stabization and fusion for unstable fracture with neuro deficit