VIQ - Spine Flashcards
@# 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.
@# 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
@# 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.
@# (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) QUESTION 56
A 40-year-old builder is admitted unconscious to the Emergency Department following an accident at work. Derails of the accident are unclear, but one witness describes scaffolding collapsing. He undergoes an emergency CT head and cervical spine, which reveals lateral displacement of both the lateral masses of Cl. How may such an injury be described?
A Atlanto-axial subluxation
B Clay shoveller’s fracture
C Dens fracture
D Hangman’s fracture
E Jefferson’s fracture
E Jefferson’s fracture
@# (Ped) 27. A 6-year-old child attends A&E with neck pain and tenderness after landing badly whilst trampolining in a neighbour’s back garden. Which of the following findings is most concerning?
A. C2/3 subluxation.
B. Overhang of the lateral masses of C1 on C2 of 6 mm.
C. An atlanto-dens interval (ADI) of 6 mm.
D. Prevertebral soft tissue of 6 mm at C3.
E. Anterior wedging of C3.
- C. An atlanto-dens interval (ADI) of 6 mm.
There are appearances that are normal for a paediatric cervical spine, which would be considered pathological in an adult and of which it is important to be aware.
Pseudo-subluxation at C2/3 and C3/4 is common (it was observed in 46% of patients less than 8 years old at C2/3 in one study and has been seen up to 14 years).
The anterior aspects of the spinous processes of C1, C2, and C3 should line up within 1 mm of each other on flexion and extension (assessed by drawing the posterior cervical line, a line from the anterior aspect of the spinous process of C1 to the equivalent point at C3).
The anterior aspect of the spinous process of C2 is allowed to pass through, touch, or lie up to 1 mm behind the posterior cervical line in physiological subluxation.
The normal ADI (the distance between the anterior aspect of the dens and the posterior aspect of the ring of the atlas) in adults is 3 mm, but is normal up to 5 mm in children.
‘Pseudo-Jefferson’ fractures (pseudospread of the lateral masses of C1 on C2) can be seen on the peg view, and up to 6 mm of displacement is common up to 4 years old and may be seen in patients up to 7 years old.
Anterior wedging of up to 3 mm of the vertebral bodies should not be confused with compression fracture. This finding can be profound at C3.
Prevertebral swelling of 6 mm or less is considered normal at C3. Widening of prevertebral soft tissues in children can be due to expiration, and if suspected, a repeat lateral film in inspiration and mild extension should be performed.
@# 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
@# 49. A 52-year-old woman presents with gradually increasing gait disturbance and lower limb sensory symptoms. An MRI of her spine is performed and this shows an anteriorly placed intradural, but extramedullary spinal mass.It is fairly markedly low signal on T1WI and T2WI, and shows only miminal patchy enhancement post administration of intravenous gadolinium. What isthe most likely diagnosis?
A. Neurofibroma.
B. Schwannoma.
C. Lymphoma.
D. Metastasis.
E. Meningioma.
- E. Meningioma.
Spinal meningiomas are typically iso- to hypointense on T1WI and slightly hyperintense onT2WI. There is usually strong and homogeneous enhancement with gadolinium. However, some meningiomas may contain calcification and are typically the only intradural extramedullarytumours to do so.
Some meningiomas can be heavily calcified and such a meningioma is being described in the question. These will remain dark on all MRI sequences and demonstrate onlylittle contrast uptake (in the non-calcified areas).
Schwannomas, neurofibromas, and metastases would not typically be hypointense on T2WI.
Meningeal lymphomas are very rare and usually manifest as diffuse thickening of nerve roots and/or multiple enhancing nodules.
@# 50. You are asked to protocol an MRI scan that is specifically being performed to look for vertebral metastatic disease. The radiographer complains that you have asked for too many sequences. Which of the following sagittal sequences is likely to be least helpful for the purposes of your examination?
A. STIR.
B. T2 fast SE with fat saturation.
C. T2 fast SE.
D. T1 fast SE.
E. T1 GE out of phase.
- C. T2 fast SE.
T2 fast SE is probably the least useful sequence when specifically looking for vertebral marrow deposits because the metastases are less conspicuous, typically being high signal on a background of high-signal fatty marrow.
On STIR and T2 fast SE with fat saturation, the metastases typically stand out as being of increased signal on a background of dark marrow because of the fat saturation techniques.
On T1 fast SE sequences, the metastases typically stand out as being lowsignal on a background of high-signal fatty marrow.
Finally, T1 GE out-of-phase imaging is also good for looking for vertebral metastatic disease. This is a sequence with a specific echo time corresponding to the time it takes for water and fat protons to move exactly 180° out of phase. In the normal adult human, the medullary bone of the vertebral bodies contains approximately equal amounts of water and fat protons. In out-ofphase conditions, the signal of both will cancel out, leaving the vertebrae completely black. In the case of vertebral pathology, however, the signal will increase and, as such, vertebral metastases (or other lesions) will clearly stand out.
@# (MSK) 37 A middle-aged gentleman who is otherwise well was shown to have coarse, vertically aligned trabeculae on a lumbar spine radiograph. A comprehensive range of blood tests were all normal. A CT of his spine was performed which showed a `pepperpot’ pattern with small dots of high density on axial images. The cortical margins were well preserved. What is the most likely diagnosis?
a Paget’s disease
b Haemangioma
C Metastatic prostate carcinoma
d Multiple myeloma
e Lymphoma
37 Answer B: Haemangioma
Haemangiomas are confined to trabecular bone. Their characteristic appearance is due to resorption of trabeculae by enlarged vascular channels and thickening of the remaining trabeculae.
@# 65 A 60-year-old woman was admitted with severe back pain. She had a past medical history of breast cancer and was on tamoxifen. She underwent an MRI scan for further assessment. What feature makes an osteoporotic fracture more likely than metastatic disease?
a Multiple levels affected
b A focal paraspinal mass
C Normal pedicles
d Convex posterior border of the vertebral body
e An epidural mass
65 Answer C: Normal pedicles
Features that are suggestive of a bony metastasis are: a bowed posterior border of the vertebral body, abnormal signal in the pedicles, an epidural or paraspinal mass and multiple lesions. Features suggestive of osteoporotic wedge fractures are: low signal on both Ti- and T2-weighted imaging, spared normal marrow signal and multiple compression fractures.
@# 67 A 60-year-old woman was admitted with immobility and was found to have a raised ESR. The remainder of her blood tests were normal. On T1-weighted MR there was some nodularity along the nerve roots with nodular contrast enhancement along the cauda equina. What is the most likely diagnosis?
a Drop metastasis from ependymoma
b Metastatic breast cancer
C Sarcoid
d Dural sepsis
e Meningioma
67 Answer B: Metastatic breast cancer
Drop metastases are most commonly seen in the paediatric population and are most commonly due to PNETs, medulloblastomas, ependymomas, germinomas and pinealoblastomas. In adults metastatic breast and melanoma are common causes. The above description is very typical. Irregularity along the surface can also be seen.
@# (MSK) 41 A 19-year-old female presented with lower back pain and a lumbosacral X-ray showed an expansile lyric lesion in the right sacrum. The margins were well defined and there was no softtissue mass visible. No other lesions were suspected. What is the most likely diagnosis?
a Multiple myeloma
b Osteoid osteoma
C Chordoma
d Giant cell tumour
e Aneurysmal bone cyst
41 Answer D: Giant cell tumour (GCT)
GCTs are characteristically well defined with a non-sclerotic margin and are most frequently seen in young adults aged between 20 and 40 years. Most GCTs occur in the long bones, but a number do occur in the spine where they tend to affect younger patients and to be three to four times more common in the sacrum than rest of spine.
@# (MSK) 60 A 29-year-old male presented with difficulty walking and was found to have a complex sensory deficit. After investigation he was found to have an astrocytoma of the spinal cord. Which area is most likely to be involved?
a Brainstem
b Cervical spine
C Thoracic spine
d Lumbar spine
e Sacrum
60 Answer C: Thoracic spine
Almost two-thirds occur in the thoracic spinal cord, although half involve the cervical cord as they usually extend over a long region of cord (approximately seven segments on average).
@# 61 A six-year-old child presented with gait problems and neurologic deficit. An MRI of the brain and whole spine was performed. There was a diffuse abnormality in the upper thoracic cord extending over approximately five vertebral levels. The lesion appeared intramedullary in location and was hypo- isointense on Ti and hyperintense on T2-weighted images with enhancement on Ti following IV Gadolinium. A syrinx was seen more superiorly. What is the most likely diagnosis?
a Ependymoma
b Transverse myelitis
C Astrocytoma
d Metastases
e Haemangioblastoma
61 Answer C: Astrocytoma
The commonest intramedullary lesions are astrocytoma and ependymoma. Astrocytomas are the most common cord tumour in children and the cervical cord is the commonest location followed by the thoracic cord. Multisegmental involvement is common and they are often associated with a syrinx and cysts. Despite being low grade they tend to enhance strongly with contrast.
Ependymomas are more common in adults and occur in the conus medullaris and filum terminale. They are generally slow growing and cause vertebral body scalloping. Cysts and haemorrhage are common.
