Spine Flashcards
(Ped) 9. A 4-year-old girl with low-grade fever and back pain has an elevated Erythrocyte Sedimentation Rate (ESR) but normal White Cell Count (WCC). Diskitis is considered. Which is the best answer regarding diskitis?
A. Usually affects children 4-10 years old
B. Thoracic spine is most commonly affected
C. Usually involves 3 consecutive disc spaces
D. Decreased marrow intensity on 2 consecutive vertebrae on T1 MR is characteristic
E. Radiographs are usually positive before bone scan
D. Decreased marrow intensity on 2 consecutive vertebrae on T1 MR is characteristic
Diskitis is the most common paediatric spine pathology.
Staphylococcus aureus is the most common causative organism.
The peak ages are 6 months-4 years and 10-14 years.
L3-4 and L 4-5 are most commonly affected sites.
(Ped) 10. An eccentric mass expands the cord on MR of a 5-year-old boy. The mass is isointense on T1 and hyperintense on T2. Which is the most common intramedullary neoplasm in children, exhibiting these features?
A. Ependymoma
B. Astrocytoma
C. Ganglioglioma
D. Haemangioblastoma
E. Subependymoma
B. Astrocytoma
Astrocytomas appear as homogenously ill-defined cord tumours, with poorly defined margins and patchy irregular enhancement with gad. Masses can take form of eccentric irregular tumour cysts, polar cysts & syrinxes
@# 28. A follow-up of a young man under the care of the neurooncologists reveals a drop in metastases. Which statement is most true?
A. Drop metastases tend to be in the upper spine
B. Metastases within the spinal canal are usually ventral
C. Glioblastoma is the commonest cause of drop metastases
D. Are associated with positive CSF cytology in approximately 10% of cases
E. Usually demonstrates homogenous enhancement with contrast
E. Usually demonstrates homogenous enhancement with contrast
Drop metastases are usually dorsal in location in the spinal canal.
Medulloblastomas are the most common cause of drop metastases.
A higher percentage of CSF cytology is positive.
(MSK) 30. A 16-year-old girl who has recently moved from India to the UK has back pain. Considering tuberculous spondylitis:
A. 10% of skeletal TB involves the spine
B. Infection usually begins in the posterior part of the vertebral body
C. Medial bowing of the psoas shadow on plain film may indicate an abscess
D. The upper thoracic spine is most commonly affected
E. Calcification within a psoas abscess is highly likely to represent TB
E. Calcification within a psoas abscess is highly likely to represent TB
50% of skeletal TB involves the spine, with the lower thoracic and upper lumbar regions being most commonly affected.
It usually begins at the anterior vertebral body.
A psoas abscess may cause lateral bowing of the psoas shadow on plain film.
@# 42. Which is a cause of solitary dense pedicle rather than erosion/absence?
A. Osteoblastoma
B. Metastatic carcinoma
C. Neurofibroma
D. Tuberculosis with paravertebral abscess
E. Aneurysmal bone cyst
- A Osteoblastoma is a cause of a solitary dense pedicle
- Which is most likely to represent an intramedullary mass lesion?
A. Ependymoma
B. Meningioma
C. Neurofibroma
D. Arachnoid cyst
E. Abscess
A. Ependymoma
Other intramedullary masses include astrocytomas are dermoids (lipoma/teratomas), acutely expanding infarcts and haematoma.
- Which is the most common cause of erosion of the odontoid peg?
A. Rheumatoid arthritis
B. SLE
C. Ankylosing spondylitis
D. Psoriasis
E. Down’s syndrome
A. Rheumatoid arthritis
Rheumatoid arthritis is the most common cause of erosion of the odontoid peg.
(MSK) 47. On review of a casualty film of a patient involved in a road traffic accident, which of the following is an unstable cervical spine fracture?
A. Unilateral facet dislocation
B. Clay shovellers
C. Jefferson
D. Burst
E. Extension tear drop
C. Jefferson
Unstable fractures include bilateral facet dislocation, flexion teardrop, hangman’s, hyperextension dislocation, Jefferson, odontoid and atlanto-occipital dislocation
(Ped) 2) A 14-year-old boy who is a keen gymnast and fast bowler gives a history of several months of central low back pain that suddenly worsened during a game of cricket when he also developed bilateral shooting pains in his legs. There is no overt deformity on clinical examination, but lower back tenderness with generally restricted movement is noted. He undergoes radiographic, CT and MR imaging. What is the most likely radiological finding to explain the patient’s current symptoms?
a. herniated intervertebral disc
b. discitis
c. Scheuermann’s disease
d. spondylolysis
e. spondylolisthesis
e. spondylolisthesis
Back pain in adults is common and most frequently non-specific.
In contrast, back pain in children is less common and often caused by a serious underlying condition.
Spondylolysis is a defect in the pars interarticularis, the weakest part of the vertebra, and is an acquired condition even in childhood, where it is usually due to repetitive microtrauma in athletically active children.
In isolation, it does not cause neurological symptoms, but bilateral defects can allow slippage of one vertebra over another, creating an abnormality of alignment, a spondylolisthesis.
Disc herniation in children is rare and occurs as a result of a traumatic event rather than degeneration. It is lateral.
Scheuermann’s disease is associated with a kyphotic deformity.
(MSK) 4) CT of the cervical spine is performed on an intubated emergency patient who was a restrained driver in a high-speed motor vehicle collision. This reveals bilateral C2 pedicle fractures. What is the most likely underlying mechanism of injury?
a. hyperflexion and rotation
b. hyperextension followed by hyperflexion
c. axial loading
d. hyperextension and traction
e. hyper-rotation
d. hyperextension and traction
The fracture described is a hangman fracture. This involves either the pedicles or pars interarticularis of C2 bilaterally.
The mechanism is usually extension and traction (as caused during hanging).
Hyperflexion injuries produce anterior tear-drop or of a vertebral body wedge fractures.
Axial loading can produce a burst fracture of C1 (Jefferson’s fracture) or a vertebral body elsewhere in the spine.
Hyperflexion and extension are associated with longitudinal ligament injury.
Hyperrotation is associated with soft-tissue injury or facet joint dislocation.
(MSK) 7) A child passenger is admitted to accident and emergency following a road traffic collision. Radiographs of the spine show a horizontal fracture involving the vertebral body and pedicles of L2. Associated injury to which of the following abdominal organs is most likely?
a. duodenum
b. pancreas
c. spleen
d. liver
e. rectum
a. duodenum
The spinal injury described is a Chance fracture, a fracture through the vertebral body and pedicles caused by hyperflexion, therefore causing compression of the spine anteriorly and distraction posteriorly.
This injury typically occurs in back-seat passengers wearing a lap seat belt during a road traffic collision.
In children, there is a 50% incidence of associated intra-abdominal organ injury.
Retroperitoneal organs are most vulnerable, being closest to the spine. Duodenal injuries are most common, and have a significant associated mortality. The pancreas is also commonly injured due to its retroperitoneal location
11) Degenerative spinal vertebral body endplate changes, as seen on MRI, may have which of the following appearances?
a. type I – high T1W and low T2W signal
b. type I – low T1W and low T2W signal
c. type II – high T1W and high T2W signal
d. type II – low T1W and high T2W signal
e. type II – high T1W and low T2W signal
c. type II – high T1W and high T2W signal
The endplates in degenerative disc disease have three described appearances during their evolution, which are also known as Modic changes.
Type I (marrow oedema) changes show low signal on T1W and high signal on T2W sequences.
Type II (fatty marrow) changes show high signal on both T1Wand T2W sequences.
Type III (sclerosis) changes are low signal on both T1W and T2W sequences.
(MSK) 11) You receive a referral while on call from the orthopaedic consultant regarding a middle-aged woman with a long history of simple back pain. She has attended accident and emergency complaining of worsening lower lumbar pain with a several-hour history of progressive urinary retention, faecal incontinence, saddle anaesthesia and mild bilateral leg weakness. Which method of imaging would you recommend as most appropriate?
a. plain radiography
b. myelogram
c. CT
d. CT myelogram
e. MRI
e. MRI
Bilateral lower limb involvement suggests a myelopathy rather than a radiculopathy. The presence of urinary and bowel symptoms and saddle anaesthesia suggests compression of lumbosacral nerve roots. This complex of symptoms is cauda equina syndrome and is considered an orthopaedic emergency because of the likelihood of permanent neurological impairment, particularly affecting the autonomic supply to the bladder or bowel, which can result in permanent incontinence if surgery is delayed. The Royal College of Radiologists recommends proceeding straight to MRI in patients who have ‘red flag’ signs.
(Ped) 15) Of the following findings on a cervical spine radiograph in a 10- year-old child, which is abnormal in the context of a traumatic injury?
a. anterior wedging of the C3 vertebral body
b. anterolisthesis in flexion at C2–3
c. prevertebral soft-tissue thickness of 15 mm at C6
d. predental space of 6 mm in flexion
e. predental space of 3 mm in neutral
d. predental space of 6 mm in flexion
The maximum predental space is 2.5–3 mm in an adult and 5 mm in a child. Any widening suggests injury to the alar ligamentous complex in the context of trauma.
Other causes of widening are Down’s syndrome, rheumatoid arthritis, neurofibromatosis and osteogenesis imperfecta.
Anterior wedging of C3 and pseudosubluxation at C2–3 and C3–4 are within normal limits in children.
Additionally, prevertebral soft tissues can be greater than in the adult, certainly up to 100% of the anteroposterior dimension of the vertebral body at the C6 level.
16) A 46-year-old female presents with back pain and increasing weakness of the lower limbs. An MR scan shows a lesion in the cord at the level of T11. Which of the following features would suggest an ependymoma rather than demyelination?
a. multiple lesions
b. expansion of the cord
c. high signal on T2W images
d. enhancement with gadolinium
e. peripheral low signal on all sequences
b. expansion of the cord
Ependymomas are the commonest tumour of the spinal cord in adults, accounting for 40–60% of cord tumours. They present with a long history of pain, and sensory or motor disturbance. Less commonly, bladder and bowel dysfunction may occur. Expansion of the cord is more often seen with ependymomas than with demyelination.
Both lesions may enhance and have high signal on T2W images, but multiplicity is more often seen with demyelination.
Peripheral low signal, usually indicating haemosiderin, is not a feature of either of these lesions.
(MSK) 18) In a patient who presents with acute femoral nerve radiculopathy, which of the following MRI sequences is the most useful in the diagnosis of a far lateral upper lumbar vertebral disc protrusion?
a. sagittal STIR
b. sagittal T1
c. sagittal T2
d. axial STIR
e. axial T2
e. axial T2
The far lateral disc protrusion is the least common type of symptomatic disc herniation. It distinguishes itself from the posterolateral herniation in that the disc ruptures outside the spinal canal, lateral to the root foramen. The disc, instead of tethering the traversing nerve root, compresses the more rostral nerve root that has already exited the root foramen. The neurological symptoms therefore correspond to a lesion at the upper disc level, often leading to confusion in the diagnosis. It is also difficult to diagnose radiologically, as the far lateral location isusually not detected on the sagittal images but only on axial images. STIR is an inversion recovery sequence that suppresses fat and so highlights areas of increased fluid. However, it is not sensitive when the herniation is outside the fluid-filled spinal canal; therefore, the T2W gradient echo sequence is better at detecting far lateral disc herniation.
(MSK) 26) On plain radiographs of the neck in a 60-year-old man, which feature is most likely to support a diagnosis of diffuse idiopathic skeletal hyperostosis rather than ankylosing spondylitis?
a. enthesopathy
b. confluent intervertebral bony bridging
c. sparing of the posterior elements
d. sparing of the sacroiliac joints
e. changes limited to the thoracic spine
d. sparing of the sacroiliac joints
Diffuse idiopathic skeletal hyperostosis (DISH) is an ankylosing disorder of the spine.
It is most commonly seen in the thoracic region but may involve cervical and lumbar regions.
Diagnostic criteria are of flowing calcification along the anterolateral border of at least four vertebral bodies, relative preservation of intervertebral disc height, and absence of sacroiliac joint or apophyseal involvement.
These three criteria aid differentiation of spondylosis deformans, intervertebral osteochondromatosis and ankylosing spondylitis respectively.
Extra-spinal manifestations of DISH include Achilles tendinosis, tennis elbow, calcaneal and olecranon enthesopathy and dysphagia.
Whiskering is seen radiographically at tendinous insertions, particularly of the pelvis.
(MSK) 27) A lumbar spinal MRI is performed on a young man of south-east Asian origin for back pain and pyrexia of unknown origin. It reveals an anterior paraspinal soft-tissue mass at levels L1 to L3 centred at the L2–3 intervertebral disc. It is located deep to and displaces the anterior longitudinal ligament, and extends into the left psoas muscle. The mass returns intermediate signal on T1W images and high signal on T2W images. There are oedematous changes in the adjacent vertebral bodies, but the intervertebral discs are spared. What is the most likely infectious organism?
a. Mycobacterium tuberculosis
b. Actinomyces
c. HIV
d. Staphylococcus aureus
e. Aspergillus fumigatus
a. Mycobacterium tuberculosis
The musculoskeletal system is affected in only 1–3% of tuberculous infections, but the spine is the most common skeletal location affected, accounting for 50% of musculoskeletal tuberculosis.
Tuberculous spondylitis (or Pott’s disease) can result in significant neurological sequelae.
A history of pulmonary infection may or may not be present.
The infection usually begins in the anterior vertebral body via haematogenous spread.
The intervertebral discs are frequently involved, and the loose internal structure of the disc allows the infection to disseminate more widely, often resulting in paraspinal or psoas abscess.
Calcification within the abscess is very specific for tuberculosis.
The disease process often leads to vertebral collapse with gibbous deformity and obliteration of the disc space. However, elevation of the anterior ligaments by subligamentous abscess allows tracking superiorly and inferiorly, and classically spares the disc.
Tuberculosis characteristically results in little reactive sclerosis or periosteal reaction, which helps to distinguish it from pyogenic infections.
(MSK) 31) Plain radiographs of the spine in a 40-year-old man performed following a road traffic collision reveal a slightly expanded midthoracic vertebral body with coarse vertical trabeculations. Subsequent CT shows a ‘polka-dot’ appearance to the same vertebral body in the axial plane. What is the most likely disorder affecting the vertebra?
a. aneurysmal bone cyst
b. osteoid osteoma
c. haemangioma
d. compression fracture
e. osteopoikilosis
c. haemangioma
Metastatic disease, myeloma and lymphoma are the most common malignant spinal tumours, and haemangioma is the most common benign tumour of the spine.
The appearances described are characteristic of a vertebral haemangioma. On MRI, these lesions typically appear of mottled low-to-high signal on T1W images depending on the degree of fat present, and of very high signal on T2W images.
Other primary osseous lesions of the spine are more unusual but may exhibit characteristic imaging features that can help develop a differential diagnosis.
Radiological evaluation of a patient who presents with osseous vertebral lesions often includes radiography, CT and MRI. The complex anatomy of the vertebrae means that CT is more useful than conventional radiography for evaluating lesion location and assessing bone destruction.
The diagnosis of spinal tumours is based on patient age, topographic features of the tumour and lesion pattern as seen on imaging.
45) A 21 year old presents with back pain, increasing over time. There are no neurological symptoms. A radiograph of the lumbar spine shows a grade II spondylolisthesis at L5–S1. Which of the following features would suggest the presence of bilateral spondylolysis as the cause?
a. narrowing of AP diameter of spinal canal at L5–S1
b. widening of AP diameter of spinal canal at L5–S1
c. lucencies through the laminae of L5
d. sclerosis of the pedicles of L5
e. reduced height of the L5–S1 disc
b. widening of AP diameter of spinal canal at L5–S1
Spondylolysis (pars defect) is seen in 3–7% of the population, with 50% being symptomatic.
L5 is the most commonly affected level.
There are fractures through the pars interarticularis, which may be unilateral or bilateral.
Spondylolisthesis can occur only when pars defects are bilateral.
The AP diameter of the canal is widened, as the vertebral body and pedicles are detached from the posterior elements and migrate anteriorly.
Narrowing of the canal is seen with other causes of spondylolisthesis, particularly degenerative causes.
Sclerosis of one pedicle is seen with unilateral pars defects, as the contralateral pedicle undergoes reactive sclerosis due to excessive stress.
(MSK) 36) A 40-year-old man falls down the stairs and remains unconscious for several hours. On admission to hospital, he is found to have bilateral upper limb weakness, patchy sensory loss, full power in the lower limbs and a normal level of consciousness. Plain radiographs of the cervical spine and CT of the brain are normal. On MRI of the cervical spine, there is a small area of oedema identified within the cord. Clinical symptoms persist for 4 days following injury. What is the most likely diagnosis?
a. central cord syndrome
b. anterior cord syndrome
c. SCIWORA (spinal cord injury without radiological abnormality)
d. spinal shock
e. Brown-Se’quard syndrome
a. central cord syndrome
In trauma, an incomplete spinal cord injury is one in which there is any degree of sparing of motor or sensory function distal to the site of injury, whereas complete cord injury results in complete lack of neurological function distal to the injury.
The diagnosis can be made only in the absence of spinal shock, a transient spinal cord concussion.
Central cord syndrome is the most common incomplete injury, and is associated with hyperextension injury in middle-aged patients; injury to centrally located grey matter in the cord causes a greater motor neurological deficit in the upper than in the lower extremities. Sensory involvement can be variable, and bowel and bladder function may be affected.
Anterior cord syndrome, caused by anterior spinal vascular insufficiency, causes complete motor paralysis with sparing of the posterior columns.
SCIWORA is seen in children, when the elastic cervical spine deforms sufficiently to cause cord injury but without any radiological findings.
Brown-Se´quard syndrome results from hemitransection and causes ipsilateral muscle paralysis and contralateral hyperaesthesia to pain and temperature.
(MSK) 43) A middle-aged male patient who has previously undergone partial discectomy for radiculopathy, has a lumbar spine MRI due to a recurrence of his symptoms. T1W images show a low-signal area of tissue contiguous with the previously operated intervertebral disc and impinging upon the adjacent exiting nerve root. Which single additional finding favours a diagnosis of postoperative fibrosis over recurrent disc protrusion?
a. high signal on STIR sequence
b. enhancement with intravenous gadolinium
c. evolution at 6-month serial imaging
d. oedema in the surrounding bone
e. low signal on T2W images
b. enhancement with intravenous gadolinium
In MRI of the spine in postoperative discectomy patients with recurrent or persistent radiculopathy, a T1W sequence with intravenous gadolinium enhancement is added to distinguish between postoperative epidural fibrosis (or scarring) and recurrent disc herniation.
Both can have similar, low-signal appearances on unenhanced T1W and T2W images, but fibrosis will show enhancement with gadolinium whereas recurrent disc prolapse will not.
Difficulties arise where both conditions exist concurrently, and fibrosis that is not causing nerve root irritation may also enhance.
The importance of distinguishing between the two is that surgical treatment is indicated for recurrent disc herniation but is of no value in treating postoperative fibrosis, also known as failed back syndrome.
(MSK) 37) Vertebral sclerosis confined to the upper and lower endplates with preservation of the intervertebral disc space (‘rugger jersey spine’), is seen most commonly with which underlying condition?
a. osteoporosis
b. discitis
c. mucopolysaccharidosis
d. Paget’s disease
e. renal osteodystrophy
e. renal osteodystrophy
The ‘rugger jersey spine’ appearance refers to sclerotic bands along the superior and inferior endplates of the thoracic and lumbar vertebral bodies.
These bands represent accumulation of excess osteoid and result in a striped appearance of the vertebral bodies.
Despite being poorly mineralized, the accumulated osteoid appears opaque on plain radiographs because of its increased volume compared with that of normal bone.
The ‘rugger jersey spine’ is said to be almost pathognomonic for the osteosclerosis seen with the secondary hyperparathyroidism of chronic renal failure.
Renal osteodystrophy is a term for the constellation of musculoskeletal abnormalities occurring with chronic renal failure.
Osteoporosis and Paget’s disease are more likely to affect the whole of the vertebrae diffusely.
Discitis usually causes a reduction in the intervertebral disc space on radiographs, with indistinct endplates.
The mucopolysaccharidoses result in anterior vertebral body beaking rather than sclerosis.
59) A 47-year-old female presents with gradual onset back pain over 4 weeks, with associated pyrexia and tenderness at the thoracolumbar junction. Radiographs show destruction of the endplates at the T12–L1 disc level. Which of the following features on further imaging would suggest tuberculous over pyogenic discitis as a cause?
a. single-level involvement
b. paravertebral, soft-tissue mass
c. epidural abscess
d. disc-space loss
e. calcification
e. calcification
Tuberculous discitis tends to occur in children and adults around the age of 50 years.
It most commonly affects T12–L1, compared with pyogenic discitis, which tends to occur more distally.
Tuberculous discitis often affects more than one level contiguously.
Paravertebral masses and epidural abscesses are seen as complications in all types of discitis, but calcification within an abscess is virtually diagnostic for tuberculosis.
Disc-space loss is also seen in all types of discitis, although it tends to be better preserved with tuberculous infection.
(Ped) 63) A 12-year-old presents with increasing back pain over 2 weeks associated with malaise. He has mild pyrexia. Plain films of the lumbar spine show reduced disc space between the second and third lumbar vertebrae with loss of clarity of the endplates. What investigation would be most likely to help make the diagnosis?
a. CT
b. MRI
c. bone scan
d. labelled white cell scan
e. gallium scan
b. MRI
Discitis is the commonest paediatric spinal disease. It is secondary to bacterial invasion of the disc through the endplate. Plain films typically show reduced disc-space height and loss of clarity of the endplates in the acute phase. MRI is the best investigation, as it is the most sensitive. Reduced T1 signal is seen in the adjacent marrow due to oedema, with initially variable, then increased, T2 signal. Complications such as epidural abscess are well demonstrated. CTwill show the endplate changes and any paravertebral inflammatory mass. Bone scans and white cell scans have much poorer sensitivity than MRI, though this is improved with the use of SPECT.
(MSK) 67) In reviewing a fracture of the spine at the thoracolumbar junction in a major trauma case, which single indicator on CT is most sensitive for inferring instability?
a. widened facet joints
b. two-column malalignment
c. soft-tissue swelling
d. rotational abnormality
e. increased intervertebral disc space
b. two-column malalignment
The spine can be divided anatomically into three columns:
the anterior column contains the anterior longitudinal ligament, anterior half of the vertebral body and anterior annulus fibrosus;
the middle column contains the posterior half of the vertebral body, posterior longitudinal ligament and the posterior annulus fibrosus;
and the posterior column contains the posterior elements of the spine, facet joint capsule and interspinous ligaments.
Two intact columns are required for intrinsic spinal stability.
Disruption of two columns can therefore be used to infer instability.
Usual traumatic patterns are anterior and middle, or posterior and middle, disruption.
Isolated middle column interruption can occur after trauma or surgery, or as a congenital abnormality, and is also considered potentially unstable.
74) A 65-year-old man presents with back stiffness and painful hips. Radiographs of the thoracolumbar spine and pelvis show ossification of the iliolumbar and sacroiliac ligaments with whiskering of the ischial tuberosities. Which of the following additional features is most likely to be seen on the spine radiographs?
a. flowing osteophytes over several vertebral levels
b. squaring of vertebral bodies
c. reduced disc spaces
d. sclerosis of vertebral bodies
e. posterior longitudinal ligament calcification
a. flowing osteophytes over several vertebral levels
The pelvic features are suggestive of diffuse idiopathic skeletal hyperostosis (DISH). Flowing anterior vertebral osteophytes, especially in the lower thoracic region, are very suggestive of this condition, and disc spaces are usually well preserved.
Vertebral body squaring is seen in a number of conditions, including ankylosing spondylitis, but not DISH.
(MSK) 76) A 50-year-old mechanic with a long history of back pain presents to the spinal clinic complaining of sudden onset of numbness and pain over the right lateral calf and dorsum and sole of the right foot following heavy lifting. Which of the following spinal pathologies is most likely to explain the patient’s symptoms?
a. lumbar spinal stenosis
b. paracentral L4–5 disc protrusion
c. paracentral L5–S1 disc protrusion
d. far lateral L4–5 disc protrusion
e. central L5–S1 disc protrusion
b. paracentral L4–5 disc protrusion
Degenerative disc disease of the spine is one of the leading causes of functional incapacity and chronic disability in the working population, affecting both men and women.
Although there is no universally established nomenclature for describing disc herniation,
‘protrusion’ is commonly used if the herniation is broader than it is deep
and ‘extrusion’ if it is deeper than it is broad.
A disc ‘bulge’ is used to describe a herniation that is very broad based and may even be circumferential, with a generalised disc bulge being one that affects at least half of the periphery. As a result of the strong posterior longitudinal ligament, posterior disc herniation is often paracentral, i.e. to the side of the midline. This can result in compression of the transiting nerve root in the lateral recess, which is the one that will exit at the level below.
A lateral disc herniation narrowing the neural foramen compresses the exiting nerve root. Therefore, for a given intervertebral disc, a paracentral herniation will affect the nerve that exits one level below, whereas a lateral protrusion affects the nerve root at that level.
(MSK) 81) Which of the following is not an appropriate indication for percutaneous polymethylmethacrylate cement vertebroplasty?
a. progressive osteoporotic deformity
b. painful osteoporotic collapse
c. painful haemangioma
d. painful osteoid osteoma
e. painful metastases
d. painful osteoid osteoma
Percutaneous cement vertebroplasty is a treatment for vertebral compression fractures that involves the injection of acrylic bone cement into the vertebral body in order to relieve pain, stabilize fractured vertebrae or, in some cases, restore vertebral height. Current guidelines from the National Institute for Health and Clinical Excellence (NICE), regarding the use of vertebroplasty in the UK, state that it may be used for pain relief in patients with severe painful osteoporosis with loss of height, compression fractures of the vertebral body, symptomatic vertebral haemangioma and painful vertebral body tumours (metastases or myeloma). Review of current evidence indicates some level of pain relief in 58–97% of patients.
(MSK) 82) On MRI of the spine demonstrating vertebral body collapse, which additional feature favours an underlying diagnosis of malignancy rather than osteoporosis?
a. bone fragment retropulsion
b. focal low signal in the vertebral body on T1W images
c. diffuse intermediate signal in the vertebral body on T2W images
d. no enhancement with gadolinium
e. convex posterior border to the vertebral body
e. convex posterior border to the vertebral body
A convex bulge involving the whole posterior border of the vertebral body strongly suggests vertebral body expansion by tumour invasion, and is only very rarely a feature of osteoporosis. Other findings on MRI suggestive of malignancy include a soft-tissue mass, involvement of the pedicles, and heterogeneous high signal on T1W post-contrast or T2W images.
Retropulsion of bone fragments, focal T1 low signal or an isointense appearance on T1W or T2W images suggests osteoporotic collapse.
(MSK) 88) On radiographs and MRI of the spine performed for lower back pain with clinical signs of radiculopathy, which of the following features favours a diagnosis of discitis rather than degenerative disc disease?
a. vacuum phenomenon in the discs
b. reduced disc space
c. intermediate signal posterior to the vertebral body on T1W images
d. vertebral endplate low signal on T1W images
e. Schmorl’s nodes
c. intermediate signal posterior to the vertebral body on T1W images
Intermediate signal in the extradural space on T1W images is the most common appearance of extradural abscess formation.
The most common primary focus of infection is discitis, but abscess formation may also be spontaneous. Patients particularly at risk are those with a history of diabetes mellitus, intravenous drug use, trauma, haemodialysis or recent surgery (particularly dental).
MRI features of extradural abscess include iso- or slight hyperintensity on T1W images when compared with the spinal cord.
High signal on T2W and proton density sequences makes it difficult to differentiate abscess from CSF, but these sequences are useful, as osteomyelitis and paravertebral abscess are well visualized as high-signal lesions.
Administration of intravenous gadolinium contrast characteristically demonstrates diffuse enhancement of the solid component of the abscess.
(MSK) 92) Vertebral bone marrow oedema, seen as low signal on T1W and high signal on T2W MR images, occurs typically in all but which of the following conditions?
a. degenerative disc disease
b. multiple myeloma
c. osteoporotic collapse
d. spondylolysis
e. ankylosing spondylitis
b. multiple myeloma
Multiple myeloma is a malignant condition of plasma cells that commonly shows infiltration of the bone marrow, best seen on MRI.
Patterns of infiltration can be classified as focal, diffuse or variegated.
Although marrow infiltration returns similar signal to marrow oedema on T1W and T2W images, infiltration will show diffuse enhancement following administration of intravenous gadolinium.
The pattern of infiltration also differs. Infiltration will be patchy and randomly distributed throughout the vertebral bone.
In contrast, bone oedema occurs adjacent to its cause, being linear at the endplates in the case of degenerative disc disease, and linear with a fracture line in osteoporotic collapse, in the pedicles adjacent to spondylolysis or at the entheses in ankylosing spondylitis.
(Ped) 92) An 8-year-old girl presents with back pain. Clinically, there is a double-curve scoliosis convex to the left in the thoracic region and to the right in the lumbar region. There is no focal neurology. MRI shows the conus behind the L3 vertebral body, and the filum terminale is 3 mm in thickness at the L5-S1 level. A high-signal lesion is seen on T1W and T2W images in the canal behind the L5 and S1 vertebral bodies. What is the most likely diagnosis?
a. diastematomyelia
b. meningocele
c. syringomyelia
d. tethered cord
e. developmental scoliosis
d. tethered cord
Tethering of the cord results in the conus lying lower than normal and is associated with scoliosis, thickening of the filum terminale (>2 mm at the L5-S1 level on axial T1 image) and spinal lipoma.
Less frequent associations are Chiari malformations, syrinx, myelomeningocele, diastematomyelia and dermal sinus.
Diastematomyelia is a midline sagittal cleft in the cord, often with a bony/fibrous septum.
Syringomyelia is dissection of cerebrospinal fluid through the cord, producing high T2 signal within the cord. This is associated with several neurological abnormalities.
Developmental scoliosis occurs in adolescent girls, is convex to the right and has no associated neurological symptoms.
(MSK) 94) A 65-year-old man undergoes radiographs of the lumbar spine and pelvis for lower back pain. A destructive lytic lesion is identified in the midline of the inferior sacrum with internal areas of calcification. Subsequent MRI reveals a heterogeneous lesion replacing much of the sacrum, which returns moderate low signal on T1W and high signal on T2W images, with a soft-tissue component extending into the presacral soft tissues. The lesion shows patchy moderate enhancement with intravenous gadolinium. What is the most likely diagnosis?
a. metastasis
b. giant cell tumour
c. aneurysmal bone cyst
d. chordoma
e. plasmacytoma
d. chordoma
Chordomas arise from notochordal rests and therefore almost always occur in the midline. They are the most common primary malignant sacral tumour and account for 2–4% of all malignant tumours of bone. They are found at all ages but most commonly occur in the fourth to seventh decades of life. Approximately half develop in the sacrococcygeal region. There is usually a large soft-tissue component and the tumour may extend across the intervertebral disc space or sacroiliac joint. Overall, the most common sacral lesion is metastasis due to the high red marrow content, but other primary malignant lesions include myeloma, Ewing’s sarcoma and lymphoma. The most commonly found benign tumours are giant cell tumours and aneurysmal bone cysts. Despite being relatively common in the rest of the spine, haemangiomas and osteoid osteomas are rare.
10 A patient presents with bladder dysfunction and leg weakness. MRI of the spine reveals a solitary intradural, extramedullary tumour of the thoracic spinal cord. It is posteriorly located and is of high signal intensity of T2W.
What is the most likely diagnosis?
(a) Nerve sheath tumour
(b) Leptomeningeal metastasis
(c) Chordoma
(d) Meningioma
(e) Astrocytoma
(d) Meningioma
Of the listed options, only nerve sheath tumours, meningiomas and leptomeningeal metastasis are typically intradural and extramedullary (chordomas are extradural and astrocytomas are intramedullary). Although nerve sheath tumours are more common, meningiomas are more likely if the tumour is solitary, posterior and does not contain areas of low signal intensity on T2W
(MSK) 17 You are asked to review a series of plain films of the cervical spine of an adult patient. Which of the following is abnormal?
(a) On the lateral view, the distance between the anterior arch of C1 and the anterior aspect of the odontoid peg is 2 mm
(b) On the lateral view, the soft tissues anterior to C2 are 9 mm thick
(c) Harris’ white ring is incomplete in its inferior aspect
(d) On the lateral view, the C4-5 interspinous distance is 30% greater than the CS-6 interspinous distance
(e) On the lateral view, the soft tissues anterior to C6 are 20 mm thick
(b) On the lateral view, the soft tissues anterior to C2 are 9 mm thick
The distance between the anterior arch of C1 and the anterior aspect of the odontoid peg should be no more than 3 mm in an adult.
On the lateral view, the maximum width of the prevertebral soft tissues is: 7 mm at C1-4, 22 mm at C5-7.
Harris’ ring is often incompletE;i in its inferior aspect.
On the long AP view, no single interspinous distance should be more than 50% wider than the one immediately above or below it.
(Ped) 27 A 14 year old boy presents with mid/ lower back pain. He is noted to be kyphotic on examination. A lateral X-ray of the thoraco-lumbar vertebrae shows anterior wedging of the T8- 10 vertebral bodies. What is the most likely diagnosis?
(a) Ankylosing spondylitis
(b) Eosinophilic granuloma
(c) Morquio’s syndrome
(d) Osteogenesis imperfecta
(e) Scheuermann’s disease
(e) Scheuermann’s disease
Scheuermann’s is thought to be caused by herniation of disc material through congenital end-plate defects during the adolescent growth spurt (presents 13-17 yrs). It accounts for 31 % of cases of back pain in adolescent boys and is located in the thoracic (75%) or thoracolumbar spine (25%). At least one vertebral body needs to be involved with anterior wedging of >5° (usually 3-5 are involved), and there must be kyphosis of >35°. The posterior aspect of the vertebral body is protected by posterior articulation. The other listed conditions are potential causes of kyphosis in children.
@# 32 An MR of the spine in a neonate reveals two separate hemichords in two separate dural tubes. Which type of split cord malformation does this represent?
(a) Type I
(b) Type II
(c) Type Ill
(d) Type IV
(e) Type V
(a) Type I
This is a type I malformation, also known as diastematomyelia. A type II of malformation comprises two hemicords within a single dural tube, also known as diplomyelia. There is no type III, IV or V malformations.
(MSK) 37 An MRI examination of the lumbar spine demonstrates endplates with reduced signal intensity on T1W and increased signal intensity on T2W. What is the most appropriate diagnosis?
(a) Normal
(b) Type I Modic change
(c) Type II Modic change
(d) Type Ill ty1pdic change
(e) Type IV Modic change
(b) Type I Modic change
Modic degenerative changes are bone marrow and endplate changes adjacent to degenerative lumbar intervertebral discs; they are commonest at the L4-L5 and L5-S1 level. Modic II is more prevalent, but Modic I changes are more likely to be symptomatic. Type I changes have MRI appearances of fluid (low T1, high T2), type II changes have the characteristics of fat due to red marrow replacement (high T1 and T2), and type Ill changes are due to sclerosis (low on T1 and T2).
(MSK) 39 Regarding giant cell tumours, which of the following statements is true?
(a) GCT usually regresses during pregnancy
(b) It is a highly malignant lesion
(c) Surgical resection is usually curative
(d) The majority arise in the spine
(e) Vertebral body involvement is more common than the posterior elements
(e) Vertebral body involvement is more common than the posterior elements
GCTs are usually benign lesions.
Malignancy occurs in 5-10°/o of cases and is usually secondary to previous radiation therapy.
The majority of spinal lesions arise within the sacrum.
Vertebral involvement accounts for only 7% of cases: thoracic spine is the most common location, followed by cervical and lumbar regions.
They typically increase in size during pregnancy, thought to be due to hormonal influences.
GCTs tend to be locally aggressive and complete surgical resection is uncommon; adjuvant radiotherapy is often administered.
Recurrence occurs in 40- 60%, and is suggested on plain film by the presence of new areas of osseous destruction.
(MSK) 2 A gentleman presents to A&E after trauma. Plain radiographs of the cervical spine are taken. There is an abrupt transition in the alignment of the cervical spine at CS-6, with anterolisthesis of CS on CG by 3/4 of a vertebral body’s width.
Which of the following is incorrect?
(a) There is a high incidence of cord injury
(b) This is a stable dislocation
(c) The posterior ligament complex is disrupted
(d) The anterior longitudinal ligament is disrupted
(e) The facets may be in a ‘batwing’ or ‘bow-tie’ configuration
(b) This is a stable dislocation
Given the extent of anterolisthesis (>50% of a vertebral body), this is most likely to represent bilateral, rather than unilateral facet dislocation, and therefore an unstable injury.
2 A middle aged man with progressive lower-extremity weakness undergoes an MRI examination of the spine. T2W images demonstrate multiple small vessel flow voids on the cord pial surface, but no flow voids within the cord. The cord is enlarged, with oedema sparing the periphery. Which type of spinal cord arteriovenous malformation does this represent?
(a) Type I
(b) Type II
(c) Type Ill
(d) Type IV
(e) Type V
(a) Type I
This is a spinal dural AV fistula (type I), the fistula is present within the dura, producing distended draining veins on the pial surface and cord oedema secondary to venous hypertension.
5 An MRI examination of the lumbar spine demonstrates 5 mm of intravertebral disc tissue protruding beyond the margin of the vertebral body over 60% of the vertebral body circumference. What is the most appropriate diagnosis?
(a) Annular disc bulge
(b) Broad based disc herniation
(c) Focal disc herniation
(d) lntravertebral herniation
(e) Disc sequestration
(a) Annular disc bulge
In an annular disc bulge, disc tissue extends beyond the adjacent vertebral bodies by at least 3mm for more than 50% of the disc circumference. This is associated with degenerative disease and is not regarded as a true herniation.
34 Which of the following is a contraindication to percutaneous vertebroplasty?
(a) Myeloma metastasis
(b) Vertebral body haemangioma
(c) Previous vertebroplasty in an adjacent vertebra
(d) Fractures involving the posterior elements
(e) Sclerotic metastases
(d) Fractures involving the posterior elements
Other absolute contraindications include bleeding diathesis, acute fractures not responding to bisphosphonate treatment within 2 weeks and those where the level of collapse cannot be clearly defined.
(MSK) 16 A middle aged man presents with low back pain and. Faecal incontinence. MR imaging of the lumbar spine is performed and a diagnosis of chordoma is subsequently made. Regarding the chordomas, which of the following is incorrect?
(a) They typically have poor uptake of 99mTc-MDP
(b) They usually cause extensive local bone destruction
(c) They most frequently arise in the sacrum or coccyx
(d) They may have a narrow zone of transition
(e) Metastasis is common
(e) Metastasis is common
Chordomas arise from notochord remains and are therefore limited to the clivus, spine, sacrum and coccyx. Metastasis is uncommon, but when it does occur, lung secondaries are typical. Tumour size (the average size of a sacrococcygeal chordoma is 10 cm), lytic nature and location are important clues to the diagnosis.
(MSK) 36 A 35 year old man involved in an RTA presents to A&E with lower neck pain. The mechanism of injury is thought be one of flexion. Cervical and thoracic spine films are obtained. Which of the following flexion fractures would you describe as being unstable?
(a) Anterior subluxation
(b) Clay-Shoveler’s fracture
(c) Flexion teardrop fracture
(d) Unilateral facet joint dislocation
(e) Wedge compression fracture
(c) Flexion teardrop fracture
Neutral films infer stability based on fracture type; stability is a function of ligamentous injury and thus cannot be implied with 100% accuracy, if doubt remains MRI or flexion/ extension views should be obtained. The other type of unstable flexion injury is a bilateral facet joint dislocation. Unstable extension injuries include Hangman’s fracture and hyperextension-dislocation fracture; stable extension injuries include posterior arch of C1 fracture, laminar fracture, Pillar fracture, and extension teardrop fracture. Jefferson’s fracture is an unstable compression fracture, burst fracture a stable one. ‘Complex’ unstable fractures include odontoid fracture and atlanto-axial disassociation.
(Ped) 39 A 6 year old child is a passenger in an RTA. The cervical spine cannot be clinically cleared and C-spine films are requested. Which of the following findings are trauma-related rather than a normal variant?
(a) Anterior subluxation of C2 on C3
(b) Anterior wedging of the C3 vertebral body
(c) Atlanta-dens interval of 5 mm
(d) Lucent line in C3 spinous process
(e) Prevertebral space of 8 mm anterior to C3
(d) Lucent line in C3 spinous process
Cervical spine injuries in children are usually located between the occiput and C2-C3, because the spine is hypermobile (ligament laxity), there is incomplete ossification of the odontoid process, a relatively large head, and weak neck muscles. The other options are normal variants, others include absent cervical lordosis, intervertebral widening, and pseudospread of the atlas on the ‘Peg’ view (pseudo-Jefferson fracture). Pseudo-widening of the prevertebral soft tissues can be normal, related to expiration.
64 A man with lower back pain has a plain lumbar radiqgraph. The LS vertebral body has slipped forward on S1 by 60% of the body diameter. What grade spondylolisthesis does this represent?
(a) I
(b) II
(c) III
(d) IV
(e) V
(c) III
Spondylolisthesis is graded from I-IV with each grade corresponding to 25% of displacement.
(MSK) 3. A 56 year old motorcyclist has a trauma series of plain films following a road traffic accident. On evaluation of the lateral cervical spine film, which of the following soft tissue parameters would be a concerning feature?
a. Predental space of 3mm
b. Nasopharyngeal space of 7mm
c. Retropharyngeal space of 10mm
d. Retrotracheal space of 20mm
e. Decreased disc space at the C5/6 level
- c. Retropharyngeal space of 10mm
This is too wide for the retropharyngeal space. The correct acceptable limits for soft-tissue measurements are as follows:
_ Predental space 3mm in adults, 5mm in children.
_ Nasopharyngeal space (anterior to C1) 10 mm.
_ Retropharyngeal space (C2–C4) 5–7 mm.
_ Retrotracheal space (C5–C7) 22 mm.
Disc spaces should be roughly equal throughout the cervical spine. Narrowing of a disc space is due to degenerative change, but widening would be a more concerning feature.
@# (Ped) 5. A ten year old boy presents with a history of progressive gait abnormalities. Plain radiographs of the thoraco-lumbar spine show widening of the spinal canal at T8-L1. MRI demonstrates an eccentric, ill-defined, homogeneous intramedullary lesion which is hypointense to the cord on T1 and hyperintense on T2. There is patchy, irregular enhancement post-contrast. What is the most likely diagnosis?
a. Lipoma
b. Ependymoma
c. Astrocytoma
d. Ganglioglioma
e. Haemangioblastoma
- c. Astrocytoma
Astrocytoma of the spinal cord is the most common intramedullary neoplasm in children. They most commonly occur in the thoracic region (thoracic 67%, cervical 49%, conus medullaris 3%). The most common presentation is with pain and sensory deficit but they can also present with motor and gait abnormalities. Plain radiographs may demonstrate scoliosis, bone erosion and widened interpedicular distance. On MRI, the lesion is usually seen as an eccentric, homogeneous, extensive, ill-defined cord tumour that is iso- or hypointense to the cord on T1 and hyperintense in T2. There is patchy irregular gadolinium enhancement. Tumour cysts and syrinx are also common. Patients with low-grade astrocytomas have a 95% five-year survival. It is often difficult to differentiate an astrocytoma from ependymoma of the spinal cord on imaging. In this case, the age of the patient, tumour location, tumour irregularity and eccentric position within the medullar favour astrocytoma.
(MSK) 13. A middle-aged woman undergoes an MRI of the lumbar spine for longstanding lower back pain. She has no specific neurological signs and is otherwise well. MRI shows some lower lumbar spine facet joint arthropathy and a 2_2 cm well-defined rounded lesion in the L3 vertebral body. This displays high signal on both the T1 and T2 sequences. The most likely explanation for this lesion is:
a. Discitis
b. Lymphoma
c. Myeloma
d. Metastatic deposit
e. Haemangioma
- e. Haemangioma
This is most likely to be a benign haemangioma. These are relatively common lesions seen as incidental findings on spinal imaging. High signal on T1 imaging is indicative of the presence of fat within the lesion. All the other conditions would give a low-signal lesion on T1 imaging.
(MSK) 18. A 23 year old man sustains a Jefferson fracture to his cervical spine following an injury in which he dived into a shallow swimming pool, hitting his head on the bottom. Which of the following regarding his injury is incorrect?
a. Displacement of the lateral masses of C1 relative to the dens on an odontoid view indicates a transverse ligament rupture
b. Associated C2 fracture will be present in up to 30% of cases
c. Jefferson fractures are usually associated with a neurological deficit
d. Up to 50% are associated with a further cervical spine injury
e. There may be associated vertebral artery injury
- c. Jefferson fractures are usually associated with a neurological deficit
Jefferson fractures are not usually associated with neurological deficit. Although there may be retropulsion of fragments into the vertebral canal, spinal cord injury is rare due to the large dimensions of the canal at this level. Vertebral artery injury, however, must be considered and if there is concern either CTA or MRA imaging should be considered.
(MSK) 27. A 52 year old woman presents to her GP with a longstanding history of lower back pain which has suddenly worsened in severity over the past few days. An urgent MRI scan of the lumbar spine shows a right paracentral disc protrusion at the L4/L5 level. The disc impinges on the lateral recess at this level. The most likely nerve to be affected is the:
a. Cauda equina
b. Lumbar plexus
c. Right L4
d. Right L5
e. Right S1
- d. Right L5
The right L5 nerve root is the most likely to be affected as it will be sitting in the right lateral recess at the L4/5 level. The L4 nerve root will be at the exit foramen and therefore if the protrusion affects only the lateral recess then this nerve will already have exited and therefore not be affected.
@# 48. A 22-year-old woman presents with upper and lower limb neurological symptoms and signs. She is subsequently discovered on MRI to have a mass in the cervical spinal cord. Which of the following features on MRI is goingto point more towards a diagnosis of spinal cord astrocytoma, rather than ependymoma?
A. Predominant T2WI high signal.
B. Homogeneous enhancement post gadolinium.
C. Short segment of cord involvement.
D. Eccentrically placed lesion in the cord.
E. Sharply marginated lesion.
- D. Eccentrically placed lesion in the cord.
Table 6.2 illustrates the diagnostic features ofastrocytoma and ependymoma
(MSK) 53. A 34-year-old man has an MRI of the lumbar spine for lower back pain. This is normal apart from a focal lesion present in the L4 vertebral body. This is reported as a vertebral haemangioma. Which of the following MRI characteristics does this lesion most likely have?
- F
The variable proportions of vascular and fatty soft-tissue elements influence the MRI appearance of haemangiomas. Lesions with a predominantly fatty matrix show high signal intensity on T1WI, intermediate to high signal intensity on T2WI, and loss of signal on STIR or fat-suppressed T2WI. If the vascular elements predominate, the lesions appear hypointense on T1WI and extremely hyperintense on STIR and T2WI. If MRI is inconclusive, CT may be helpful in identifying the typical pattern of haemangiomatous bone replacement, such as the honeycomb, ‘soap bubble’ or ‘sunburst’ appearance.
(Ped) 60 Following minor trauma a six-year-old child has cervical spine radiographs. No cervical spine injury is identified and a diagnosis is made of pseudosubluxation. What are the likely radiographic findings?
a A line between the anterior margins of C1 and C3 spinous processes passing within 2 mm of the anterior margin of the C2 spinous process
b 5-mm distance between the odontoid and the anterior arch of the axis
C Anterior displacement of up to 5 mm of the C2 vertebral body on the C3 vertebral body on flexion views
d Increase in the anterior displacement of the C2 vertebral body on the C3 vertebral body on extension views and reduction on flexion views
e 7-mm distance between the odontoid and anterior arch of the axis
60 Answer A: A line between the anterior margins of Cl and C3 spinous processes passing within 2 mm of the anterior margin of the C2 spinous process
Pseudosubluxation is normal mobility of the upper cervical spine, particularly at C2/3 and C3/4, which occurs in approximately 40% of children younger than eight years old. It results from immature lax ligaments and horizontally aligned facets. Swischuck’s line, drawn between the anterior margins of the spinous processes of Cl and C3, should pass through or lie within 2 mm of the anterior margin of the spinous process of C2. More than 2 mm is suggestive of pathological subluxation. In pseudosubluxation the anterior displacement occurs in flexion and should reduce with neck extension.
