RD spine Formatted

Question 1

1. A 19 yo man with lower back pain and no other history. MRI shows 25mm long, 2mm wide lesion in conus (LAS – 15 x 2mm). Bright on T2, iso on T1 (LAS – fluid-filled). Most likely:
   a. Ventricular terminalis
   b. Syrinx
   c. Myelomeningocele
   d. Meningioma
   e. Astrocytoma
   f. Ependymoma
   g. Haemangioblastoma

Answer 1

a. Ventricular terminalis T if 15mm, likely F if 25mm though; asymptomatic; Mild cystic dilatation of distal central spinal cord canal without cord signal abnormality or enhancement; size 2-4mm transverse, rarely exceeds 2cm in length; no septation;

b. Syrinx = T = fluid-intensity intramedullary cord cleft; can cause pain (StatDx); should be T1 hypointense though; right age group for primary syrinx; most common location is lower cervical cord

1. A 19 yo man with lower back pain and no other history. MRI shows 25mm long, 2mm wide lesion in conus (LAS – 15 x 2mm). Bright on T2, iso on T1 (LAS – fluid-filled). Most likely:

a. Ventricular terminalis T if 15mm, likely F if 25mm though; asymptomatic; Mild cystic dilatation of distal central spinal cord canal without cord signal abnormality or enhancement; size 2-4mm transverse, rarely exceeds 2cm in length; no septation;

b. Syrinx = T = fluid-intensity intramedullary cord cleft; can cause pain (StatDx); should be T1 hypointense though; right age group for primary syrinx; most common location is lower cervical cord

c. Myelomeningocele F

d. Meningioma F extramedullary

e. Astrocytoma F T1 hypo to iso, T2 mildly hyper, eccentric location, usually in thoracic cord; cystic tumours should have cord expansion.

f. Ependymoma F expect haemosiderin cap and satellite cysts or syrinx; can occur at conus; usually older age (35-45 yo);

g. Haemangioblastoma F often cyst with mural nodule with associated syrinx, but not all fluid intensity (Lin p310) If neoplastic should have surrounding abnormal T2 signal.

Question 2

Haemangioblastoma in spine. which is true
a. if multiple a/w with Osler weber rendu
b. less than 1 % of spinal tumours
c.c most common in thoracic spine

Answer 2

A = F (assoc/ w/ VHL, although 75% are sporadic)
B = F (1-6% of spinal cord neoplasms)
C = T thoracic (50%) > cervical (40%)

Random facz
-Haemangioblastomas are benign vascular lesions that do not undergo malignant degeneration. They are WHO grade 1 in the 5th Edition (2021)
-most common location is the thoracic cord (50%).
-80% solitary, when multiple then think VHL
-associated tumour cyst or syrinx is common (50-100%)

Question 3

1. Regarding the lumbar spine, which is LEAST correct.
   a. Annular tears are typically secondary to trauma
   .b. Focal herniation refers to <25% disc circumference.
   c. Broad based herniation refers to 25-50% disc circumference.
   d. Far lateral disc protrusion at L3/4 impinges the L3 nerve root.
   e. Posterolateral disc protrusion at L3/4 impinges the L4 nerve root.

Answer 3

a. Annular tears are typically secondary to trauma. ?F Disruption of concentric collagenous fibers comprising the anulus fibrosus. Abnormal signal focus (HIZ) at posterior disc margin on MRI. Direct association with disc degeneration, often due to repetitive trauma.

RY* 2014 nomeclature update
- Annular fissure should be used because secondary to degeneration, annular tear is no longer a correct term (implies trauma related).
- Herniation is <25%
- Asymmetrical bulge >25%
- Bulge is circumferential.
- Broad based not part of terminology
https://www.thespinejournalonline.com/article/S1529-9430(14)00409-4/fulltext

Question 4

Least supportive of EG in kid with back pain and loss of vertebral body height at T7
a. mass.
b. involvement of posterior elements.
c. wedge shaped compression.

Answer 4

*LW: Preferred answer is B:

A. Small Paraspinal soft tissue has common.
B. Involvement of posterior elements is rare / excitedly unusual / uncommon finding. Thus favoured answer being least supportive.
C. Vertebral plana is a common feature, while wedge compression or uneven lateral compression is enchanted in early stages.
(radiographics 1992)

C = F? = LCH causes collapse of vertebral body to thin disc; adjacent discs normal (although this is usually only seen in the textbooks as per Dr Earwaker)

A = T = Small paraspinal/epidural soft tissue component common

B = T? = posterior element more common in cervical spine; Pocket Rad Spine says posterior elements involved rarely (however Dr Earwaker disagrees)

C = F? = LCH causes collapse of vertebral body to thin disc; adjacent discs normal (although this is usually only seen in the textbooks as per Dr Earwaker)

Question 5

1) Regarding lumbar discs, which is the most correct:

i) Annular tear is secondary to trauma
ii) Focal herniation < 25%
iii) Broad-based herniation >50%
iv) Far lateral disc at L4/5 level affects L5 nerve
v) Posterolateral disc at L3/4 level affects L3 nerve

Answer 5

ii) Focal herniation < 25% T

1) Regarding lumbar discs, which is the most correct

:i) Annular tear is secondary to trauma ?F Disruption of concentric collagenous fibers comprising the anulus fibrosus. Abnormal signal focus (HIZ) at posterior disc margin on MRI. Direct association with disc degeneration, often due to repetitive trauma

.ii) Focal herniation < 25% T

iii) Broad-based herniation >50% F 25-50%

iv) Far lateral disc at L4/5 level affects L5 nerve F may affect the L4 exiting root

v) Posterolateral disc at L3/4 level affects L3 nerve F will usually affect the descending L4 rootSee details in answer for April 2011

Question 6

2) Chance fracture following MVA. Most relevant:

i) Almost universally has neurological deficit
ii) Vertebral disc distraction
iii) Spinal cord injury
iv) Flexion compression fracture of middle column

Answer 6

iii) Spinal cord injury T can have cord contusion

2) Chance fracture following MVA. Most relevant:

i) Almost universally has neurological deficit F StatDx - Neurologic injury may be present; more commonly have abdominal visceral injury

ii) Vertebral disc distraction T can occur

iii) Spinal cord injury T can have cord contusion

iv) Flexion compression fracture of middle column F

Compression injury of anterior column with distraction of middle & posterior columns (StatDx)
• Acute forward flexion of the spine across a restraining lap seat-belt during sudden deceleration causes the spine above the belt to be pushed forward & distracted from the lower, fixed part of the spine
o Distraction of middle-posterior elements/ligaments; anterior compression of vertebral body

random facz
- high association with duodenal and pancreas injury
-most commonly occurs about the upper lumbar spine (with the thoracolumbar junction accounting for ~50% of cases)
-The anterior and middle columns fail in compression, and the posterior column fails in distraction

Question 7

3) Dwarf. Low back pain radiating down both legs. Most likely cause:
i) Overexaggerated lordosis of sacrum
ii) Short pedicles
iii) Scalloping of vertebral bodies
iv) Scoliosis
v) Sacrosciatic action

Answer 7

ii) Short pedicles T combined with decreasing interpedicular distance causes spinal canal stenosis, with superimposed bony degenerative disease (StatDx)

Question 8

TB spondylitis/disciti. which is true

a. always find TB lung changes on CXR
b. cold abscess central high T1, low T2
c. noncontiguous involvement less likely than pyogenic
d. disc spared until late.
e. anterior sub ligamentous spread is more common in bacterial osteomyelitis /discitis

Answer 8

D = T = relative preservation of disc height in TB

A = F = Concomitant pulmonary tuberculosis in about 10% of patients (StatDx); about 50% of patients have obvious pulmonary disease (Neuro Req p543)

B = F = ‘cold abscess’ = a chronic abscess of slow formation and with little evidence of inflammation; T1 hypointense, T2 hyperintense, peripherally enhancing

C = F = spread of infection can occur beneath the ALL, therefore TB is more likely to have contiguous involvement

D = T = relative preservation of disc height in TBE = F

Random Facz
-spine is the most frequent location of musculoskeletal tuberculosis.
-likes anterior portion of vertebral body.

Question 9

2. Regarding spinal trauma is FALSE?

a. About 5% of patients with a primary spinal injury have another non-contiguous vertebral injury.
b. Fracture through the disc occurs in DISH
c. Cervical flexion tear-drop type fractures are associated with ventral cord injury
d. Chance fractures are almost universially associated with neurological injury
e. A limbus vertebra occurs most often on the anterior-superior margin of a mid lumbar vertebra

Answer 9

d) Chance fractures are almost universally associated with neurological injury F can occur, but visceral injury more common

4) Regarding spinal trauma is FALSE?

a) About 5% of patients with a primary spinal injury have another non-contiguous vertebral injury. T?

b) Fracture through the disc occurs in DISH T can occur, but are more common in the vertebral body than the disc (unlike in AS) – AJR 2009

c) Cervical flexion tear-drop type fractures are associated with ventral cord injury T

d) Chance fractures are almost universally associated with neurological injury F can occur, but visceral injury more common

e) A limbus vertebra occurs most often on the anterior-superior margin of a mid lumbar vertebra T Intraosseous disc penetration at junction of cartilaginous endplate, developing osseous rim apophysis → Small corticated bone fragment matching osseous defect of anterosuperior vertebral margin; Mid-lumbar > mid-cervical location. Anterior&raquo_space; posterior.

Question 10

chordoma least likely.
a. typically presents before age 30
b. destruction
c. soft tissue mass
d. ends of axial skeleton
e. spinal cord met is a recognised complication

Answer 10

A = F (rare in patients < 30 yrs; < 5% of chordomas present in childhood; peak incidence 5th-6th decade)

E = F can get intradural drop metastases (J Clin Neurosci. 2009 Aug;16(8):1105-7, from PAH) & bony (e.g. vertebral) metastases, but nothing about spinal cord metastases (may be most false??

)A = F (rare in patients < 30 yrs; < 5% of chordomas present in childhood; peak incidence 5th-6th decade)

B = T (lytic, destructive lesion – may involve disc, contiguous vertebrae, epidural space, etc.)

C = T

D = T (sacrum > clivus > vertebral body)

E = F can get intradural drop metastases (J Clin Neurosci. 2009 Aug;16(8):1105-7, from PAH) & bony (e.g. vertebral) metastases, but nothing about spinal cord metastases (may be most false??)

Question 11

40 yo male. destructive sacral lesion. least likely (probably most false??)

a. chrodoma
b. plasmacytoma
c. met
d. osteoblastoma
e. chondrosarcoma

Answer 11

*LW: Radprimer states most likely causes of solitary sacral mass in adult are: GCT, Chordoma, Plasmacytoma.

D = T (lytic & expansile – ‘aggressive osteoblastoma’ can cause cortical breakthrough & have wide zone of transition though!)

A = T (most common primary malignancy)

B = T

C = T

D = T (lytic & expansile – ‘aggressive osteoblastoma’ can cause cortical breakthrough & have wide zone of transition though!)

E = T (5% occur in spine & sacrum) Osteoblastoma would be least destructive, but is more common than chondrosarcoma in sacrum.

Question 12

2. 64. yo male, previously well. Sees GP with worsening back pain. Physical exam and laboratory tests are unremarkable. Plain radiograph of spine shows sclerotic T8 vertebra without loss of height. MOST APPROPRIATE subsequent investigation?

a. Radionuclide bone scan
b. MRI spine
c. Skeletal survey
d. CT thoracic spine
e. No further Ix required

Answer 12

a. Radionuclide bone scan T most likely prostate mets

Question 13

3. 34yo male with neck pain for last 2y. MRI shows intraspinal mass at cervical level. Which of following would favour an astrocytoma over Ependymoma

a. Well defined Intramedullary mass
b. Ill defined Intramedullary mass
c. Presence of hemorrhage
d. Homogeneous enhancement
e. Multiple intracranial meningomas

Answer 13

b. Ill defined Intramedullary mass T astrocytoma more likely to have ill-defined borders & spread over several vertebral levels

2. 34yo male with neck pain for last 2y. MRI shows intraspinal mass at cervical level. Which of following would favour an astrocytoma over Ependymoma

a. Well defined Intramedullary mass F ependymoma more likely to be well defined.

b. Ill defined Intramedullary mass T astrocytoma more likely to have ill-defined borders & spread over several vertebral levels

c. Presence of hemorrhage F rare in astrocytoma; haemosiderin cap common in ependymoma

d. Homogeneous enhancement F heterogeneous in astrocytoma, homogeneous in ependymoma

e. Multiple intracranial meningomas suggests NF-2, i.e. ependymoma > astrocytoma

• Astrocytoma - patchy irregular Gd-enhancement on MR

Ependydmoma enhance homogeneously in 84%.

Ganglioglioma - Patchy (65%, / no (15%) tumor enhancement
Ependymomas are more frequently hemorrhagic than astrocytomas, especially myxopapillary types at conus

ADB random facz

Ependymoma (adults)
-more common 60%
-older age by 10 years, 39 vs 29 for astro
-cervical most common, central location within cord
-haemorrhage cap
- smaller than astrocytoma, well circumscribed
- intense enhancement
-associate with NF2

Astrocytoma
- less common, younger than ependymoma
-larger ill-defined infiltrative
- patchy irregular enhancement
- uncommon haemorrhage
-eccentric in cord, thoracic cord
-assoc NF1

Question 14

4. 40yo man with 4/12 Hx increasing back pain. Plain films - destructive lesion of sacrum. CT shows soft tissue mass in sacrum, no calcification in it. MRI shows heterogeneous mass with areas of low signal on T1 and T2. MOST LIKELY?’
   a. Chordoma
   b. Plasmacytoma
   c. Chondrosarcoma
   d. Giant cell tumor of bone
   e. Osteoblastoma

Answer 14

*LW: Radprimer states most likely causes of solitary sacral mass in adult are: GCT, Chordoma, Plasmacytoma.

d. Giant cell tumor of bone T? usually no ca++, lytic, heterogeneous due to haemorrhage, necrosis and fibrous tissue.; 2nd most common primary sacral tumour after chordoma; locally aggressive; 2nd-4th decade. Locally aggressive, eccentric; involves subchondral bone, may grow across SIJ. 5-10% are malignant.3.

40yo man with 4/12 Hx increasing back pain. Plain films - destructive lesion of sacrum. CT shows soft tissue mass in sacrum, no calcification in it. MRI shows heterogenelus mass with areas of low signal on T1 and T2. MOST LIKELY?

a. Chordoma ?F most common primary sacral malignancy; > 70% have intratumoural calcification (StatDx says peripheral calcification in MSK article & amorphous intratumoural calcification in Spine article!); T1 & T2 hetero; 70% in sacrum have T2 low signal foci of haemosiderin. Arise from notochordal rests, therefore always midline/paramedian in relation to spine. Most common primary sacral malignancy (excl. lymphoproliferative), mostly 4th-7th decades, 50-60% in sacrum (35% in clivus). Locally aggressive, amorphous calcifications, may cross SIJ

.b. Plasmacytoma F possible, but less likely; lytic, destructive lesions

c. Chondrosarcoma F will have chondroid matrix calcification; lytic lesion with assocd soft tissue mass and calcifications; adults.

d. Giant cell tumor of bone T? usually no ca++, lytic, heterogeneous due to haemorrhage, necrosis and fibrous tissue.; 2nd most common primary sacral tumour after chordoma; locally aggressive; 2nd-4th decade. Locally aggressive, eccentric; involves subchondral bone, may grow across SIJ. 5-10% are malignant.

e. Osteoblastoma F rare in sacrum; May be blastic (large osteoid osteoma) or expansile & lytic (similar to ABC). Tends involve the posterior vertebral elements.

Question 15

5. 12yo male with recent onset back pain. Plain film reveals approx 60% reduction of T7 vertebral body height. Which of following findings would make the Dx of EG UNLIKELY?
   a. Involvement of other bones
   b. Surrounding soft tissue swelling
   c. Wedge-like vertebral body collapse
   d. Involvement of the posterior elements

Answer 15

*LW: Favoured answer is involvement of posterior elements:
Radiographic states: EG can initially cause wedge like or uneven lateral compression of vertebral bodies, before developing complete vertebra plana.
Often multifocal
Commonly small para spinal soft tissue mass.
Involvement of posterior elements uncommon / destruction of posterior elements is atypical - hence most unlikely.

h. Wedge-like vertebral body collapse. = F = LCH causes Collapse of vertebral body to thin disc; adjacent discs normal4.

12yo male with recent onset back pain. Plain film reveals approx 60% reduction of T7 vertebral body height. Which of following findings would make the Dx of EG UNLIKELY?

f. Involvement of other bones T often multifocal

g. Surrounding soft tissue swelling T = Small paraspinal/epidural soft tissue component can occur

h. Wedge-like vertebral body collapse. = F = LCH causes Collapse of vertebral body to thin disc; adjacent discs normal

i. Involvement of the posterior elements ? F = typically spares the posterior elements (RG) ; posterior element more commonly involved in cervical spine (StatDx);

Dr Earwaker however has shown me a case involving the posterior elements, he indicates it’s not that rare

The radiographic characteristics of a typical spinal lesion consist of complete or incomplete collapse of the vertebral body; absence of an osteolytic area; preservation of pedicles, posterior elements, and adjacent disk spaces; absence of adjacent paravertebral soft-tissue shadow; and increased opacity in the collapsed body http://radiographics.rsna.org/content/28/4/1019.full.pdf

Question 16

6. 18yo female with persistent lower back pain and scoliosis. Plain film examination reports a sclerotic left T8 pedicle lesion with associated sclerosis. Which of the following is MOST LIKELY?
   a. Osteoid osteoma
   b. Fibrous dysplasia
   c. Sclerotic met T8
   d. Early-Paget’s disease

Answer 16

a. Osteoid osteoma

Question 17

1.A young female has neck pain, dysarthria and diplopia. Non contrast CT brain and cervical spine both normal. The next most appropriate investigation is:
1.CT brain with contrast
2.MRI brain
3.Duplex ultrasound neck
4.DSA
5.LP

Answer 17

2.MRI brain - T - MR is the modality of choice (but should specify MRI + MRA?). MRI detects both the intramural thrombus and intimal flap that are characteristic of VAD. Hyperintensity of the vessel wall seen on T1 axial images is considered pathognomonic of VAD. MRA can identify abnormalities that are characteristic of the disturbed arterial flow seen in VAD. These include the presence of a pseudolumen and aneurysmal dilation of the artery. MRI and MRA are less sensitive than cerebral angiography for the detection of VAD, although they probably have equivalent specificity.

1.A young female has neck pain, dysarthria and diplopia. Non contrast CT brain and cervical spine both normal. The next most appropriate investigation is: (GC)

1.CT brain with contrast - F - possibly CTA (accessibility after hours).

2.MRI brain - T - MR is the modality of choice (but should specify MRI + MRA?). MRI detects both the intramural thrombus and intimal flap that are characteristic of VAD. Hyperintensity of the vessel wall seen on T1 axial images is considered pathognomonic of VAD. MRA can identify abnormalities that are characteristic of the disturbed arterial flow seen in VAD. These include the presence of a pseudolumen and aneurysmal dilation of the artery. MRI and MRA are less sensitive than cerebral angiography for the detection of VAD, although they probably have equivalent specificity.

3.Duplex ultrasound neck - F - demonstrates abnormal flow in 95% of patients with VAD; US signs specific to VAD (eg, segmental dilation of the vessel, eccentric channel) are detectable in only 20% of patients.

4.DSA - T - indicated when clinical suspicion is high but MRI/MRA has failed to isolate the lesion; characteristic angiographic finding in a dissected vertebral artery is the string or “string and pearl” appearance of the stenotic vessel lumen; also intimal flap / complete occlusion.

5.LP - F - patients with suspected SAH and a normal CT scan may undergo LP if VAD is not pursued by other imaging modalities. The typical presentation of VAD is a young person with severe occipital headache and posterior nuchal pain following a recent, relatively minor, head or neck injury. The trauma is generally from a trivial mechanism but is associated with some degree of cervical distortion.

Focal neurologic signs attributable to ischaemia of the brainstem / cerebellum ultimately develop in 85% of pts; however, a latent period as long as 3 days between onset of pain and development of CNS sx is not uncommon.
Symptoms of vertebral a. dissection include: Ipsilateral facial dysaesthesia (pain and numbness) - most common symptom Dysarthria or hoarseness (CN IX and X) Contralateral loss of pain and temperature sensation in the trunk and limbs Ipsilateral loss of taste (nucleus and tractus solitarius) Hiccups Vertigo Nausea and vomiting Diplopia or oscillopsia (image movement experienced with head motion) Dysphagia (CN IX and X) Disequilibrium Unilateral hearing loss [eMedicine; Craniocervical arterial dissection RG 2008

Question 18

2.64 year old male presents with worsening back pain. Otherwise well. Normal examination. Sclerotic lesion T8 vertebral body without loss in height. The most appropriate next investigation is:

1.Skeletal survey
2.CT T-spine
3.MRI T-spine
4.Bone scan
5.No further investigation required at this stage

Answer 18

4.Bone scan - T - would evaluate if solitary / multifocal, and if active. 2.

64 year old male presents with worsening back pain. Otherwise well. Normal examination. Sclerotic lesion T8 vertebral body without loss in height. The most appropriate next investigation is: (GC)

1.Skeletal survey - F

2.CT T-spine - F - need to image whole spine, whereby MRI would give more information regarding discs etc. as other potential causes for back pain.

3.MRI T-spine - F - need to image whole spine.

4.Bone scan - T - would evaluate if solitary / multifocal, and if active.

5.No further investigation required at this stage - F - at least check PSA.

Bone tumours favouring vertebral bodies: CALL HOME Chordoma, ABC, Leukaemia, Lymphoma, Haemangioma, Osteoid osteoma/Osteoblastoma, Myeloma/Mets, EG/Ewing.
Ddx widespread sclerotic lesions: metastases - prostate, (breast), lung, bladder, pancreas, stomach, colon, carcinoid, brain Paget’s disease sarcoma myelofibrosis mastocytosis [Dahnert]

Question 19

3.Which of the following is false regarding chordomas?

1.Spinal metastases
2.Destructive lesion with soft tissue
3.Less than 30 years old
4.Occurs in both ends of the spine

Answer 19

3.Less than 30 years old - F - can occur at any age, but mainly 30-70yo (mean 50yo). M>F 2:1. Can occur at < 30 years, but uncommon.

3.Which of the following is false regarding chordomas? (TW)

1.Spinal metastases - T - metastases (in 5-43%) to liver, lung, bone, regional lymph node, peritoneum, skin (late) heart. (if specify spinal CORD, then would be false)

2.Destructive lesion with soft tissue - T - lobulated tumor contained within pseudocapsule. Most frequent radiographic appearance of chordoma is that of a destructuve lesion of a vertebral body centered in the midline, with a large, associated soft tissue mass.

3.Less than 30 years old - F - can occur at any age, but mainly 30-70yo (mean 50yo). M>F 2:1. Can occur at < 30 years, but uncommon.

4.Occurs in both ends of the spine - T - 50% in sacrum, 35% in clivus, 15% in vertebrae. Chordoma is the most common primary malignant tumor of the spine in adults excluding lymphproliferative neoplasms. Originates from embryonic remnants of notochord / ectopi cordal foci. Histo - cords & clusters of large bubblelike vacuolated (physaliferous) cells.Key DDx = Chondrosarcoma (also T2 hyperintense)

Question 20

4.Which of the following is more suggestive tuberculous rather than pyogenic infection of the spine?
1.Multifocal
2.Low signal on T1 and T2
3.Disc space narrowing
4.Subligamentous spread
5.Normal chest xray rules it out

Answer 20

4.Subligamentous spread - T - infection spreads beneath the ALL or PLL to adjacent vertebrae; may see skip lesions. Pyogenic infection spreads contiguously involving disc and subchondral bone; begins in disc margin in kids (highly vascularised); in adults begins in endplate with secondary disc invovlement.

4.Which of the following is more suggestive of tuberculous rather than pyogenic infection of the spine? (GC)

1.Multifocal - F - In TB there is typically more than one (up to 5-10) vertebrae involved due to subligamentous spread; upper lumber + lower thoracic (L1 most common). Pyogenic infection may involve multiple levels in 20% (esp. immunocompromised).

2.Low signal on T1 and T2 - F - non discriminating feature of spondylitis - low SI of marrow on T1, contrast enhancement of marrow +/- disc, high SI of disc (+/- marrow) on T2.

3.Disc space narrowing - F - relative preservation of disc space because TB lacks proteolytic enzymes; disc itself is preserved but fragmented (cf. rapid destruction in pyogenic infection).

4.Subligamentous spread - T - infection spreads beneath the ALL or PLL to adjacent vertebrae; may see skip lesions. Pyogenic infection spreads contiguously involving disc and subchondral bone; begins in disc margin in kids (highly vascularised); in adults begins in endplate with secondary disc invovlement.

5.Normal chest xray rules it out - F - no pulmonary lesions in 50%.

Question 21

10.Contraindications MRI . which is false
1.PPM
2.clipped aneurysm
3.Stent
4.Spinal stimulator
5.Spinal rods

Answer 21

*AJL - Contraindications have probably changed since this question was written. Can look it up at mrisafety.com if unsure.
PPM - Need to check if it is MRI safe. Most modern ones are safe.
Clipped aneurism - Need to check that it is not magnetic, most modern clips are not magnetic.
Stent - Should be safe
Spinal stimulator - Need to check if MRI safe.
Spinal rods - safe.

Previous answer
5.Spinal rods - F - heating is relatively low. Generally orthopedic implants show no deflection within main magnetic field.

10.Contraindications MRI (TW)

1.PPM - T - absolute contraindication for MRI. Even in patients where PM has been removed, remaining pacer wires could act as an antenna and induce currents, causing cardiac fibrillation.

2.clipped aneurysm - T - the presence of some intracranial aneurysm clips is an absolute contra-indication to MRI. Clip motion may damage the vessel. Only MRI if definitely know clip is non-ferrous.

3.Stent - T - less false - depending on what stent. Coronary artery stents are largely MRI safe from what I can gather, as are aortic stents. Not sure about intracranial stents, or stents elsewhere - didn’t specify in answer.

4.Spinal stimulator - T - certain implated devices are contraindicated for MR inaging becuase they are either, magnetically, electrically, or mechanically activated (cochlear implants, tissue expanders, ocular prosthesis, dental implants, neurostimulators, bone growth timulators, implantable cardiac defibrillators, implantable drug infusion pumps)

5.Spinal rods - F - heating is relatively low. Generally orthopedic implants show no deflection within main magnetic field.

Question 22

11.Paediatric C spine which is true:

1.Atlanto axial subluxation is less common than in adults
2.Anterior wedge of C3 is not a normal variant
3.Lateral displacement of lateral masses C1/2 by 6mm is a normal finding in a 4 year old
4.Injuries are more commonly lower cervical than upper

Answer 22

3.Lateral displacement of lateral masses C1/2 by 6mm is a normal finding in a 4 year old – T - Total offset (sum of both sides) of more than 6mm of the lateral masses of the atlas with respect to the odontoid is highly suggestive of rupture of the transverse ligament or avulsion of its attachments. (see below)

11.Paediatric C spine which is true: (TW)

1.Atlanto axial subluxation is less common than in adults – F - occurs 5x more common in children than adults

2.Anterior wedge of C3 is not a normal variant - F - normal variant, however age dependent: eg, anterior wedging in a 3yo at C5 is likely normal variant. However wedged body at C5 in an 8yo is likely pathologically compressed.

3.Lateral displacement of lateral masses C1/2 by 6mm is a normal finding in a 4 year old – T - Total offset (sum of both sides) of more than 6mm of the lateral masses of the atlas with respect to the odontoid is highly suggestive of rupture of the transverse ligament or avulsion of its attachments. (see below)

4.Injuries are more commonly lower cervical than upper – F - in patients under 9yo, almost all injures are to the occiput-C2 region (Imaging of Spinal Trauma in Children, Kuhns).

Above ans from: Differences between adult and paeds spinal injury (Spinal Trauma in Children, Paeds Radiol 2001)
Re: option 3. “Imaging in Pediatric Skeletal Trauma” K Johnson - “The lateral masses of C1 and C2 may be offset bilaterally in young children so that the lateral masses of C1 overhang those of C2 on the AP view, simulating a Jefferson burst fracture. This phenomenon is thought to be secondary to disparity in growth rate between the two vertebra and is most commonly seen at around 4y of age, but often up to 7y of age. Up to 6mm lateral displacement of the lateral masses of C1 relative to the odontoid is within normal limits under these circumstances. Physiological subluxation of C2/3 seen In 25 % children < 8 years. C3/4 15% note less than 3 mm, posterior line retains alignment.

Question 23

12.Fatty marrow, most likely site:
1.Rib
2.Spine
3.Femoral diaphysis
4.Prox humerus

Answer 23

3.Femoral diaphysis Red or cellular marrow (RM) is hematopoietcally active.
Hematopoietically inactive yellow marrow (YM) is composed of fat cells.
RM signal iso- / slightly hyper to muscle T1 and T2. YM iso with subcutaneous fat T1, hyperintense to muscle on T2, and iso- / slightly lower than subcut fat.
Birth - marrow predominantly hematopoietically active cells. Orderly and predictable conversion - begins in appendicular/peripheral skeleton and progresses to the axial/central skeleton.
In long bones, marrow conversion first in diaphysis, then distal metaphyses, and finally proximal metaphyses.
Adult marrow pattern reached ~25y - at this time see red marrow in axial skeleton (skull, spine, sternum, flat bones) and prox ends of humeri and femurs), yellow marrow elsewhere. May see subchondral islands of red marrow in proximal humeral epiphyses.
The adult pattern is characterized by the presence of red marrow only in portions of the vertebrae, sternum, ribs, clavicles, scapulae, skull, and innominate bones and in the metaphyses of the femora and humeri.

Question 24

13.Posterior scalloping, false:
1.Communicating hydrocephalus
2.Psoriasis
3.Achondroplasia
4.Neurofibromatosis
5.Ependymoma

Answer 24

2.Psoriasis - F

Posterior vertebral body scalloping
dural ectasia (NF, Marfan’s, Ehlers-Danlos),
syrinx,
spinal canal tumor,
congenital (achondroplasia, mucopolysaccharidoses, OI),
acromegaly

Question 25

14.Intraspinal tumours, which is true:
1.Gliomas enhance uniformly
2.Meningiomas most commonly arise in the cervical spine
3.Meningiomas are hyperintense to cord on T2
4.Nerve sheath tumours are hyperdense to disc on CT
5.Haemangioblastomas are associated with prominent veins

Answer 25

5.Haemangioblastomas are associated with prominent veins - T - nonglial highly vascular discrete nodular masses abutting leptomeninges with prominent dilated and tortuous vessels on posterior cord surface. Assoc with vHL. Majority intramedullary (75%). Thoracic cord 50% > cervical cord 40%.

14.Intraspinal tumours, which is true: (TW)

1.Gliomas enhance uniformly - F - patchy irregular Gd-enhancement on MR (astrocytoma). Ependydmoma enhance homogeneously in 84%. Patchy (65%, / no (15%0 tumor enhancement in gangliogliomas of spinal cord.

2.Meningiomas most commonly arise in the cervical spine - F - thoracic 82%, cervical on anterior cord surface near foramen magnum is 2nd most common. 50% are intradural extramedullary

3.Meningiomas are hyperintense to cord on T2 – F - Lesions usually isointense to spinal cord on both T1-weighted and T2-weighted images. Lesions are sometimes hypointense on T1-weighted images and hyperintense on T2-weighted images.

4.Nerve sheath tumours are hyperdense to disc on CT – F - On CT, they appeared as tumours isodense or slightly hypodense compared to muscle tissue: low attenuation due to high lipid content of myeline from Schwann cells / entrapped fat / endoneural myxoid tissue with high water content (Antoni B areas).

5.Haemangioblastomas are associated with prominent veins - T - nonglial highly vascular discrete nodular masses abutting leptomeninges with prominent dilated and tortuous vessels on posterior cord surface. Assoc with vHL. Majority intramedullary (75%). Thoracic cord 50% > cervical cord 40%.

Question 26

15.Lumbar spine, which is true:

1.Spondylolisthesis at L4 most commonly associated with spondylolysis
2.Disc herniation is most common posterolaterally
3.Degenerative changes most prominent in mid lumbar spine
4.Height of disc is directly proportional to the size of the protrusion
5.Limbus vertebrae is of superior end plate

Answer 26

2.Disc herniation is most common posterolaterally – T - 49% posterolateral. primer paracentral, commenest posterolateral direction (Fig. 18), because the posterior longitudinal ligament is weakest in this part

15.Lumbar spine, which is true: (–) (TW)

1.Spondylolisthesis at L4 most commonly associated with spondylolysis - F - degenerative at L4, spondylolysis more common at L5

2.Disc herniation is most common posterolaterally – T - 49% posterolateral. primer paracentral, commenest posterolateral direction (Fig. 18), because the posterior longitudinal ligament is weakest in this part

3.Degenerative changes most prominent in mid lumbar spine - F - 90% discs L4 or L5

4.Height of disc is directly proportional to the size of the protrusion – F - crap

5.Limbus vertebrae is of superior end plate - ?F - marked true can be inferior as well eg postero-inferior in lumbar spine. limbus vert- form of cartilaginous node (Schmorls nodes) resulting from a defect in a vertebral body; it is caused by herniation of part of the nucleus pulposus beneath the ring apophysis prior to fusion of the apophysis to the vertebral body.

Trauma appears to be responsible for most cases. The distorted interfaces between the intervertebral disc and adjoining vertebral body are well seen on CT scans and MR This one still open for discussion but plenty of pictures show “limbus vert” in post inferior region

Question 27

16.With regards to Osteomyelitis – discitis of the spine, which is false:

1.The commonest organism is staph
2.Changes may be mimicked by Modic 1 changes on T1 and T2
3.Cervical spine is the most common site
4.Involvement of multiple vertebral bodies is most likely TB
5.Rapid loss of height favours pyogenic over TB

Answer 27

3.Cervical spine is the most common site – F - lumbar spine; thoracic in Potts’s disease

Question 28

17.Regarding imaging of paediatric cervical spine, which is true?:
1.Atlantoaxial dislocation occurs less in children than adults
2.Anterior wedging of C3 is a normal variant
3.Normal CT excludes spinal cord injury
4.Displacement of lateral mass of C1/2 of greater than 6 mm is normal
5.Injury to cervical spine is more common in lower than upper spine

Answer 28

2.Anterior wedging of C3 is a normal variant - T - normal variant, however age dependent: eg, anterior wedging in a 3yo at C5 is likely normal variant. However wedged body at C5 in an 8yo is likely pathologically compressed.

17.Regarding imaging of paediatric cervical spine, which is true?: (TW)

1.Atlantoaxial dislocation occurs less in children than adults – F - occurs 5x more common in children than adults

2.Anterior wedging of C3 is a normal variant - T - normal variant, however age dependent: eg, anterior wedging in a 3yo at C5 is likely normal variant. However wedged body at C5 in an 8yo is likely pathologically compressed.

3.Normal CT excludes spinal cord injury - F - SCIWORA - most studies of traumatic myelopathy in children report an incidence of SCIWORA greater than 20% (Medscape). Range 5-65%

4.Displacement of lateral mass of C1/2 of greater than 6mm is normal - F - Total offset (sum of both sides) of more than 6mm of the lateral masses of the atlas with respect to the odontoid is highly suggestive of rupture of the transverse ligament or avulsion of its attachments. (see below)

5.Injury to cervical spine is more common in lower than upper spine – F - in patients under 9yo, almost all injures are to the occiput-C2 region (Imaging of Spinal Trauma in Children, Kuhns). Above ans from: Differences between adult and paeds spinal injury (Spinal Trauma in Children, Paeds Radiol 2001) Also see answers from Aug 2006 Qu 1.

Question 29

18.With regards to red marrow, which bones converts to fatty marrow first
1.Spine
2.Ribs
3.Pelvis
4.Proximal humerus
5.Femoral diaphysis

Answer 29

5.Femoral diaphysis Red or cellular marrow (RM) is hematopoietically active. Hematopoietically inactive yellow marrow (YM) is composed of fat cells. RM signal iso- / slightly hyper to muscle T1 and T2. YM iso with subcutaneous fat T1, hyperintense to muscle on T2, and iso- / slightly lower than subcut fat. Birth - marrow predominantly hematopoietically active cells. Orderly and predictable conversion - begins in appendicular/peripheral skeleton and progresses to the axial/central skeleton. In long bones, marrow conversion first in diaphysis, then distal metaphyses, and finally proximal metaphyses.

Question 30

19.Spinal cord injury without radiographic abnormality and hyperextension injuries of the cervical spine in children

1.Occurs in 2-5% of spinal injuries
2.Is more common in older children
3.Can hae a delayed onset, usually within up to 48h
4.Is thought to be due to lack of elasticity of ligaments resulting in cord distraction and compression

Answer 30

3.Can have a delayed onset, usually within up to 48hrs - T - delayed onset of neurological damage is reported to occur in 6-54% of cases, usually within 48h

19.Spinal cord injury without radiographic abnormality, which is true: (TW)

1.Occurs in 2 - 5% of spinal inuries - F - overall incidence of SCIWORA varies from 5-65%

2.Is more common in older children - F - SCIWORA is commoner in younger children and in this group is often severe with a poor prognosis for recovery

3.Can have a delayed onset, usually within up to 48hrs - T - delayed onset of neurological damage is reported to occur in 6-54% of cases, usually within 48h

4.Is thought to be due to lack of elasticity of ligaments resulting in cord distraction and compression - F - is postulated that excessively elastic ligaments and other developmental features of the immature spine allow transient excessive movement during trauma, resulting in cord distraction or compression.

Question 31

20.Paediatric C-spine, false

1.Injury more common in upper spine
2.Atlanto-occiptal subluxation occurs more commonly in children
3.A good CT excludes injury
4.Anterior Wedge at C3 is a normal variant

Answer 31

3.A good CT excludes injury - F - SCIWORA - most studies of traumatic myelopathy in children report an incidence of SCIWORA greater than 20% (Medscape). Range 5-65%

20.Paediatric C-spine, false (TW)

1.Injury more common in upper spine spine - T - in patients under 9yo, almost all injures are to the occiput-C2 region (Imaging of Spinal Trauma in Children, Kuhns).

2.Atlanto-occiptal subluxation occurs more commonly in children - T - occurs 5x more common in children than adults

3.A good CT excludes injury - F - SCIWORA - most studies of traumatic myelopathy in children report an incidence of SCIWORA greater than 20% (Medscape). Range 5-65%

4.Anterior Wedge at C3 is a normal variant - T - T - normal variant, however age dependent: eg, anterior wedging in a 3yo at C5 is likely normal variant. However wedged body at C5 in an 8yo is likely pathologically compressed.

Question 32

21.In MRI of the spine in normal adults, the following structures enhance with Gadolinium:
1.Bone Marrow
2.Disc fibrocartilage
3.Dorsal root ganglia
4.Spinal cord
5.Nerve roots

Answer 32

3.Dorsal root ganglia - T - the DRG are void of a blood-nerve barrier and therefore will normally enhance after the injection of contrast.

21.In MRI of the spine in normal adults, the following structures enhance with Gadolinium: (TW)

1.Bone Marrow - F - (if single answer, this is probably false). Bone marrow enhancement cannot be adequately assessed with standard T1 SE sequences. Results of previous studies have indicated enhancement is only marginal. 2003 radiology article showed that Gd enhancement of normal bone marrow can be readily observed with ultrafast dynamic MR imaging.

2.Disc fibrocartilage - F

3.Dorsal root ganglia - T - the DRG are void of a blood-nerve barrier and therefore will normally enhance after the injection of contrast.

4.Spinal cord - F - BBB 5.Nerve roots - F - Blood-nerve barrier - but probably not as well developed as in endonurial capillaries of peripheral nerve.

Question 33

23.Regarding MS, which is true?

1.50% have plaques in cervical cord
2.Black hold is seen on T2 images
3.Lesions in the spinal cord are usually perpendicular to the long axis of the cord
4.Lesions more juxtacortical compared to those in small vessel disease

Answer 33

1.50% have plaques in cervical cord - T - up to 80% (cord only ~30%) of all MS patients have spinal involvement. Of these, cervical cord lesions account for 2/3 of cases. ie. Around 50% have cervical cord plaques. Seen as eccentric involvement of the dorsal and lateral elements abutting the subarachnoid space.

23.Regarding MS, which is true? (GC + TW)

1.50% have plaques in cervical cord - T - up to 80% (cord only ~30%) of all MS patients have spinal involvement. Of these, cervical cord lesions account for 2/3 of cases. ie. Around 50% have cervical cord plaques. Seen as eccentric involvement of the dorsal and lateral elements abutting the subarachnoid space.

2.Black hole is seen on T2 images. F - well-marginated discrete foci of T2 hyperintensity (represents loss of hydrophobic myelin which results in an increase in water content)

3.Lesions in the spinal cord are usually perpendicular to the long axis of the cord - F - atrophic plaques are orinetated along spinal cord asix. Length of plaque usually less than 2 vertebral body segments. Plaques are orientated perpendicular to the corpus callosum in the brain (perpendicular calloseptal T2 hyperintensities). (Dahnert; MRI atlas of spine)

4.Lesions more juxtacortical compared to those in small vessel disease. F - lesions may be subependymal and periventricular as in small vessel disease. MS may also involve corpus callosum, internal capsule, centrum semiovale, corona radiata, optic n./chiasm/tract, brainstem (trigeminal root entry zone), cerebellar peduncles, cerebellum. 10% of MS plaques occur in gray matter.

Question 34

24.The following are features of pyogenic infection of the spine:

1.Staphylococcus aureus is the most common causative organism
2.The thoracic spine is the most common site
3.The characteristic radionuclide bone scan is increased uptake in two adjacent vertebra bodies
4.Classically the infection starts within the body of the vertebra
5.Osteoblastic reaction with sclerosis is more common than with tuberculosis

Answer 34

multiple true answers.
1 is probably the best

24.The following are features of pyogenic infection of the spine: (TW)

1.Staphylococcus aureus is the most common causative organism - T - Staph accounts for more than 50% of cases in most series from developed countries. Vertebral OM is primarily a disease of adults, most pts >50yo. Increased incidence with age. M>F 2x. Increasing incidence prob due to IV devices, increasing age of population, and IVDU.

2.The thoracic spine is the most common site - F - lumbar > thoracic > cervical for hematogenous spread. Upper lumbar / lower thoracic (L1 most commonly) in Pott’s disease

3.The characteristic radionuclide bone scan is increased uptake in two adjacent vertebra bodies - T - see below.

4.Classically the infection starts within the body of the vertebra – F - endplate. See below.

5.Osteoblastic reaction with sclerosis is more common than with tuberculosis – T - reactive sclerosis/periosteal reaction typically absent in Potts disease (Dahnert). Reactive sclerotic changes remain localized and the remainder of the vertebral structures are often spared in spinal TB (UTD).

Question 35

25.In regard to spinal meningiomas

1.Bone invasion is a feature
2.Reactive bone sclerosis is a prominent feature
3.Tumour calcification is a prominent feature
4.They are typically isointense with cord on T1 and T2 weighted MR
5.Multiple spinal meningiomas suggest neurofibromatosis Type I

Answer 35

4.They are typically isointense with cord on T1 and T2 weighted MR images - T - isointense with cord on T1Wi and T2WI. +/- dural tail. Rapid and intense enhancement after Gd-DTPA.

26.In regard to spinal memningiomas: (TW)

1.Bone invasion is a feature - F - bone erosion in <10%

2.Reactive bone sclerosis is a prominent feature - F

3.Tumour calcification is a prominent feature - F - solid smoothly marginated mass isodense with skeletal muscle on CT.

4.They are typically isointense with cord on T1 and T2 weighted MR images - T - isointense with cord on T1Wi and T2WI. +/- dural tail. Rapid and intense enhancement after Gd-DTPA.

5.Multiple spinal meningiomas suggest neurofibromatosis Type I - F - NF2 (MISME - multiple inherited schwannomas, meningiomas, ependymomas)

Question 36

27.Ependymomas which one is false

1.Myxopapillary type tend to affect conus
2.Cellular type commonest in thoracic cord in adults
3.Can cause communicating hydrocephalus
4.Calcification is rare compared with intracranial ependymomas
5.Presence of cysts and haemorrhage would favor ependymoma vs astrocytoma

Answer 36

2.Cellular type commonest in thoracic cord in adults – F - cellular type is most common. Likes the cervical and thoracic spine, cf myxopapillary. Ependymomas 44% occur cervical cord alone; 23% with extension into thoracic cord; 26% thoracic cord alone; conus medullaris 7%.

27.Ependymomas (TW)

1.Myxopapillary type tend to affect conus - T - special variant of ependymoma of lower spinal cord. Most common neoplasma of conus medullaris (83%).

2.Cellular type commonest in thoracic cord in adults – F - cellular type is most common. Likes the cervical and thoracic spine, cf myxopapillary. Ependymomas 44% occur cervical cord alone; 23% with extension into thoracic cord; 26% thoracic cord alone; conus medullaris 7%.

3.Can cause communicating hydrocephalus - T - spinal tumors most commonly associated with hydrocephalus are spinal ependymomas or ependymoblastomas. These tumors are known to be particularly prone to subarachnoid spread. The appearance of tumor cells in the subarachnoid space can cause neoplastic arachnoiditis and development of adhesions, which result in blockage of CSF circulation (Acta Neurochirurgica 1997).

4.Calcification is rare compared with intracranial ependymomas - T - unlike intracranial ependymomas, calcification is uncommon in intramedullary ependymomas.

5.Presence of cysts and haemorrhage would favor ependymoma vs astrocytoma - T - cystic degeneration in 50%; hemorrhage at superior and inferior tumor margins. Astrocytoma haemorrhage is uncommon. The most common histology is that of the cellular type. Well-defined cuboidal or low columnar cells are arranged in a papillary fashion. However, the most common lesion of the filum terminale is the myxopapillary type, in which mucinous change also is seen. This type especially is prone to hemorrhage and can present as an unexplained subarachnoid bleed Ependymomas are more frequently hemorrhagic than astrocytomas.

Question 37

29.Syringomyelia is a recognised association of: t/f

1.Thoracic cord trauma
2.Meningeal metastases
3.Benign intracranial hypertension
4.Arachnoiditis
5.Arnold-Chiari malformation Type II

Answer 37

29.Syringomyelia is a recognised association of: (TW)

1.Thoracic cord trauma - T - Chiari I malformation 41%, trauma 28%, neoplasm 15%, idiopathic 15%.

2.Meningeal metastases - F

3.Benign intracranial hypertension - F

4.Arachnoiditis - T - interrupted flow of CSF through the perivascular spaces of cord between subarachnoid space and central canal

5.Arnold-Chiari malformation Type II - T - Chiari I and II may cause neurological symptoms by CSF flow obstruction at the foramen magnum due to tonsillar tissue and arachnoid adhesions causing syringomyelia.

Syringohydromyelia = syringiomyelia = Syrinx = (used in general manner reflecting difficulty in classification): longitudinally oriented CSF-filled cavities + gliosis within spinal cord frequently involving both parenchyma + central canal. - Hydromyelia = primary / congenital syringohydromyelia (lined by ependymal tissue) Syringomyelia = Acquired / secondary syringohydromyelia (not lined by ependymal tissue)

Random facz
syrinx
congenital (90%) or acquired in aetiology.

Congenital causes include:
-myelomeningocele
-Chiari I AND 2
-Dandy-Walker malformation
-Klippel-Feil syndrome

Acquired (secondary) causes include:
-post-traumatic
-cervical canal stenosis
-post-inflammatory
-secondary to a spinal cord tumour
-secondary to a haemorrhage
-due to vascular insufficiency

Question 38

30.The following statements regarding congenital spinal abnormalities are true: multiple t/f question

1.Diastematomyelia is typically associated with a congenital scoliosis
2.Dorsal dermal sinus most frequently occurs in the sacrococcygeal region
3.Caudal regression syndrome is associated with maternal diabetes mellitus
4.Neuroenteric cysts most commonly occur posterior to the spinal cord
5.Myelomeningocoele is associated with hydrocephalus in 70-90% of patients

Answer 38

30.The following statements regarding congenital spinal abnormalities are true: (TW)

1.Diastematomyelia is typically associated with a congenital scoliosis – T - = split cord = myeloschisis. Sagittal division of spinal cord into two hemicords (each containing a central canal, on dorsal horn, and one vertral horn). Congential malformation due to adesions between ectoderm and endoderm. Congenital scoliosis (50-75%)

2.Dorsal dermal sinus most frequently occurs in the sacrococcygeal region – F - lumbosacral (60%), sacrococcygeal (1%), ventral (8%).

3.Caudal regression syndrome is associated with maternal diabetes mellitus - T - CRS: variable degree agenesis/disruption distal neurla tube. Classically absent sacrum +/- absent distal lumbar vertebrae. Maternal diabetes significant risk factor.

4.Neuroenteric cysts most commonly occur posterior to the spinal cord – F - NE cyst = incomplete separation of foregut and notnochord iwth persistenc eof canal of Kovalevski between yolk sac + notochord; cyst connected to meninges through midline defect. Rereset of bronchopulmonary foregut malformations (pulmonary sequestration, broncho. Located anterior to spinal canal on mesenteric side of gut - posterior mediastinal mass.

5.Myelomeningocoele is associated with hydrocephalus in 70-90% of patients - T - assoc with Chiari II malformation 99%. Hydrocephalus 70-90% (requiring VP shunt in 90%). 25% of patients with hydrocephalus have spina bifida. 5% of patients with congenital scoliosis have diastematomyelia : Location: lumbosacral (60%), occipital (25%), thoracic (10%), cervical (2%), sacrococcygeal (1%), ventral (8%)

Question 39

32.Lumbar discs (multiple true)

1.have a higher attenuation than cervical discs
2.10% of disc herniations are calcified
3.most occur at L5/S1
4.MRI shows varied signal intensity of prolapsed discs
5.Central prolapse is most common

Answer 39

32.Lumbar discs: (GC)
1.have a higher attenuation than cervical discs
2.10% of disc herniations are calcified
3.most occur at L5/S1 - T
4.MRI shows varied signal intensity of prolapsed discs - T
5.Central prolapse is most common Up to 80% of free fragments will have high signal on T2WI even though the parent disc may be low signal

Question 40

33.The following cause posterior scalloping of the vertebrae: multiple true
1.Achondroplasia
2.Acromegaly
3.Sickle cell disease
4.Ependymoma
5.Lymphoma

Answer 40

33.The following cause posterior scalloping of the vertebrae: (GC)
1.Achondroplasia - T
2.Acromegaly - T
3.Sickle cell disease - F - “H-vertebra” due to compression of central portions from subchondral infarcts.
4.Ependymoma - T
5.Lymphoma - F - anterior scalloping seen in lymphadenopathy.

Question 41

36.An increased interpedicular distance occurs in: multiple answers
1.Achondroplasia
2.Meningocele
3.Diastematomyelia
4.Lipoma of the cord
5.AV Malformation of cord

Answer 41

36.An increased interpedicular distance occurs in: (GC)

1.Achondroplasia - F - narrowed IP distance due to laminar thickening. Spinal stenosis also caused by ventrodorsal narrowing due to short pedicles, and IV disc herniations. Other spinal manifestations: bullet-shaped vertebrae (anterior beaking in upper L spine, ddx Hurler’s), decreased VB height, posterior scalloping, gibbus and exaggerated sacral lordosis.

2.Meningocele - T - widening of L spine with fusiform enlargement of spinal canal. Obs US: splaying of ossification centres of laminae with cup/wedge-shaped pattern (transverse plane is most imp. for dx). XR: bony defect in neural arch, absent spinous processes, widened IPD and spinal canal. Cord tethered in 70-90%; hydrocephalus in 70-90%; Chiari II in 99%.

3.Diastematomyelia - T - sagittal division of spinal cord into two hemicords, each of which contains a central canal, 1 dorsal horn and 1 ventral horn; due to adhesions btn ectoderm and endoderm. Widened IPD, narrowed disc space with hemivertebra/butterfly/block vertebra - congenital scoliosis, spina bifida, fusion and thickening of adj. laminae; tethered cord in >50% with low conus in >75%.

4.Lipoma of the cord - T - Lipomyelomeningocoele (84%) - large spinal canal, erosioni of VB and pedicles, posterior scalloping, focal spina bifida, segmental anomalies in over 40%, confluent sacral froamina / partial sacral agenesis in up to 50%. Intradural lipoma (4%) - focal enlargement of spinal canal, narrow localised spina bifida. Fibrolipoma of filum terminale (12%) wouldn’t cause IPD widening.

5.AV Malformation of cord - F [Dahnert]

Question 42

37.Causes of vertebral body fusion include

1.TB
2.Brucellosis
3.Acromegaly
4.Gout
5.Ochronosis

Answer 42

37.Causes of vertebral body fusion include: (GC)

1.T.B. - T - Pott’s disease = destruction of VB and IV disc by MTB; 5% of pts with TB (of which half have no pulmonary lesions). Upper lumbar and lower T-spine (L1 most common); typically more than 1 (up to 5-10) verterbrae affected. Collapse of IV disc space occurs late (cf. pyogenic arthritis), demineralisation of endplates, reactive sclerosis/periosteal reaction typically absent, VB collapse (plana in kids, gibbus in adults). Fusion may be complete, the cortical margins may be reestablished, and there may be no trace of the original anatomy. [Dahnert; www.isradiology.org]

2.Brucellosis - T - ddx TB by presence of gas within disc, minimal paraspinal mass, no kyphosis, predilection for lower lumbar spine.

3.Acromegaly - F - excessive GH. Spinal changes: posterior scalloping (30%), anterior new bone, loss of disc space (weakened cartilage).

4.Gout - F - deranged purine metabolism. Spinal (and hip) involvement is rare: 1st MTP > ankles > heels > wrists > fingers > elbows; knees, shoulder, SIJ.

5.Ochronosis - T - aka Alkaptonuria. Inherited absence of homogenistic acid oxidase with excessive HA production and deposition in connective tissue, including cartilage, synovium and bone (black pigment).
Spinal changes occur middle age - lumbar spine with progressive ascension. Laminated calcification of multiple discs with narrowing of disc spaces, multilevel vacuum phenomena, osteoporosis of adjoining vertebrae, massive osteophytosis and ankylosis of spine (older patients). May see spotty Ca2+ in tissue anterior to vertebral bodies. [Dahnert]

Question 43

35.Posterior vertebral scalloping is seen in:
1.Acromegaly
2.normal variant

Answer 43

35.Posterior vertebral scalloping is seen in: (GC)

1.Acromegaly - T - in 30% of patients; secondary to increased pressure of enlarged soft tissue.

2.Normal variant - T - A minor degree of concavity in the posterior vertebrae is a normal physiologic variation and has been demonstrated in over 50% (56 of 100) of otherwise healthy individuals. [Posterior vertebral scalloping sign, Radiology 2006]