VIQ - Spine Flashcards

1
Q

@#e2 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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

@#e2 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
  1. A Osteoblastoma is a cause of a solitary dense pedicle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

@#e2 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

(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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

@# (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

A
  1. 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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

@# (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

A

E Jefferson’s fracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

@# (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.

A
  1. 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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

@#2 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.

A
  1. D. Eccentrically placed lesion in the cord.

Table 6.2 illustrates the diagnostic features ofastrocytoma and ependymoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

@#e2 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.

A
  1. 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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

@#e2 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.

A
  1. 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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

@# (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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

@# 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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

@# 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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

@#e2 (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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

@#e2 (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

A

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).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

@# 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

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

@# 62 A 26-year-old male with haemophilia developed sudden onset cauda equina syndrome and an emergency MRI of the lumbar spine was performed. A large fusiform posterior extradural mass extending from L1 to L5 was present. It was hypointense on T2-weighted images. What is the most likely diagnosis?

a Epidural abscess

b Metastasis

c Arachnoid cyst

d Neurofibroma

e Haematoma

A

62 Answer E: Haematoma

Spinal haematomas occur due to trauma, following a procedure (typically laminectomy or epidurals), during childbirth or spontaneously, particularly in those with bleeding disorders. They are usually due to venous bleeds and are typically posterior fusiform masses. They can result in a cauda equine syndrome and require prompt neurosurgical evacuation.

17
Q

@#e2 68 An 18-year-old boy was involved in a road traffic accident. He had multiple injuries and one month after his accident he still had a right Ti nerve root palsy. MRI of the brachial plexus was normal. A further MRI study of his cervicothoracic spine was performed which showed an absent right Ti nerve root. No conjoint roots were seen at C7 or T2. There was a small, well-defined area of CSF signal at the right Ti neural exit foramina. What is the most likely diagnosis?

a Lateral myelomeningocele

b Traumatic nerve root avulsion

C Tarlov cyst

d Neurogenic cyst

e Synovial cyst from the facet joint

A

68 Answer B: Traumatic nerve root avulsion

The right Ti nerve root has been avulsed. This most commonly occurs in the cervical region following severe acute traction on the upper limb such as a fall from a motorbike. Imaging typically demonstrates an absent nerve root within the neural foramina and a pseudomeningocele. If patients are not able to have an MRI, a CT myelogram could be performed.

18
Q

@# 69 A 55-year-old woman was being investigated for right lower limb weakness. On MRI there was a well-defined high signal cystic area in the right Si lateral recess. There was expansion of the right Si neural canal with bone scalloping. Nerve roots are visualised along the wall of the cyst. What is the most likely diagnosis?

a Tarlov cyst

b Myelomeningocele

C Schwannoma of right Si nerve root

d Pilocytic astrocytoma

e Haematoma

A

69 Answer A: Tarlov cyst

A Tarlov cyst is a perineural cyst arising from the nerve root. They most commonly occur in the sacral region and can cause bone scalloping from pressure effects. It is postulated that there is a ball valve effect so CSF flows into the cyst with arterial pulsations. The spinal nerves may be visualised either in the wall of the cyst or the cyst itself. They occur in 5 % of the population and are more common in women. They are usually asymptomatic but may cause symptoms such as bladder and bowel dysfunction or lower motor or sensory abnormalities.

19
Q

@#e2 (ped) 2 The paediatric team sees a neonate with respiratory distress, bradycardia and poor swallowing. Following imaging investigation the child was found to have a small posterior fossa and dysgenesis of the hindbrain. The fourth ventricle and hindbrain are displaced caudally and the tonsils and vermis are herniating through the foramen magnum. What further CNS abnormalities may be present?

a A funnel-shaped posterior fossa

b Klippel-Feil deformity

C Basilar impression

d Herniation of the cerebellar tonsils

e Lumbar myelomeningocele

A

2 Answer E: Lumbar myelomeningocele

The child has Arnold Chiari malformation (Chiari II malformation), which has the above characteristic features. It is associated with lumbar myelomeningocele in >95% of cases and syringohydromyelia. In addition it is associated with the following supratentorial anomalies:
* dysgenesis of corpus callosum (80-85%)
* obstructive hydrocephalus secondary to closure of myelomeningocele (50-98%)
* absence of septum pellucidum (40%)
* excessive cortical gyration.
It is notably not associated with basilar impression, Cl assimilation and KlippelFeil deformity

20
Q

@#e2 60 A 20-year-old man had progressive upper and lower limb weakness, worse in the lower limbs. On MR there was widening of the spinal canal with posterior vertebral scalloping between D3 and D7. On Ti- and T2-weighted imaging a well-defined high-intensity mass was present anterior to the spinal cord with atrophy of the cord at this level. The CSF space was slightly expanded immediately superior to the mass. No high signal was present in the cord on T2. What is the most likely diagnosis?

a Epidural abscess

b Epidural haematoma

C Neuroma

d Neurogenic cyst

e Meningioma

A

60 Answer D: Neurogenic cyst

The description above describes a chronic process resulting in bone remodelling and atrophy of the cord. Thus an epidural abscess and haematoma are unlikely. This mass is extramedullary but intradural. Although meningiomas and neuromas are intradural they are isointense on Ti hence the best answer is a neurogenic cyst. Neurogenic cyst is an intradural mass, which is commonly seen within the cervical and thoracic region. They are associated with other spinal abnormalities such as diastematomyelia and Klippel-Feil syndrome.

21
Q

@#e2 62 Following surgery for a herniated L4/L5 disc a 66-year-old obese patient had little symptomatic relief. An MRI scan performed in the second postoperative week revealed extradural soft-tissue material within the spinal canal, which demonstrated little enhancement following contrast. Nerve root enhancement was striking. What is the most likely diagnosis?

a Arachnoiditis

b Epidural haematoma

c Residual disc material

d Epidural fibrosis

e Neuritis

A

62 Answer C: Residual disc material

Appearances of the post-operative spine can be challenging.

In the early postoperative period, persistent symptoms are usually due to epidural haematoma, retained fragment or recurrent disc.

In the subacute and chronic stage the differential is mainly between a disc and epidural fibrosis.

Osseous abnormalities depend on the specific surgical procedure.

Epidural fibrosis occurs commonly, enhances with contrast administration and the degree of enhancement varies with time since the operation, enhancing most strongly within a year following surgery.

Neuritis, identified as intrathecal enhancement of nerve roots, is seen in approximately 20% of symptomatic patients.

Early postoperative root enhancement is common in asymptomatic patients and is considered significant only if it persists beyond at least six to eight months.