RD spine 2 formatted

Question 1

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 1

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 2

40 yo man. Destructive sacral lesion. Least likely
\:a. chordoma. 
b. plasmocytoma
c. met
d. osteoblastoma
e. chondrosarcoma.

Answer 2

Osteoblastoma would be least destructive, but is more common than chondrosarcoma in sacrum.

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)

Question 3

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 3

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

Question 4

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 4

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 5

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 5

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. 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)
4. CT brain with contrast - F - possibly CTA (accessibility after hours).
5. 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.
6. 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.
7. 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.
8. 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 6

Features of TB spondylitis

Answer 6

almost always bone destruction evident at the time of imaging, rather than just marrow oedema gibbus deformity due to preferential anterior involvement in adults posterior elements often involvedepidural and paraspinous abscesses are common and large at time of presentation; psoas abscess may be calcified absence of reactive sclerosis or periosteal reaction vertebra plana in kids; vertebra within a vertebra, ivory vertebra

Question 7

5. Regarding a destructive sacral lesion, the least likely cause would be
6. Osteoblastoma
7. Giant cell tumour
8. Chordoma
9. Chondrosarcoma
10. Plasmacytoma

Answer 7

Osteoblastoma - not that destructive

5. Regarding a destructive sacral lesion, the least likely cause would be: (GC)
6. Osteoblastoma - rarely found in sacrum. May be blastic (large osteoid osteoma) or expansile & lytic (similar to ABC). Tends involve the posterior vertebral elements.
7. Giant cell tumour - T - only 7% of GCTs involve the spine, but with respect to spinal involvement, the sacrum is the most common site. 2nd-4th decade. Locally aggressive, eccentric; involves subchondral bone, may grow across SIJ. 5-10% are malignant.
8. Chordoma - T - 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. High T2 signal.
9. Chondrosarcoma - T - lytic lesion with assoc’d soft tissue mass and calcifications; adults. High T2 signal.
10. Plasmacytoma - T – lytic, destructive lesions

Question 8

12. Fatty marrow most likely site (TW)
13. Rib
14. Spine
15. Femoral diaphysis
16. Prox humerus

Answer 8

3.Femoral diaphysis

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), 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 9

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 9

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%.
6. Intraspinal tumours, which is true: (TW)
7. 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.
8. 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
9. 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.
10. 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).
11. 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 10

16. With regards to Osteomyelitis – discitis of the spine, which is false:
17. The commonest organism is staph
18. Changes may be mimicked by Modic 1 changes on T1 and T2
19. Cervical spine is the most common site
20. Involvement of multiple vertebral bodies is most likely TB5.Rapid loss of height favours pyogenic over TB

Answer 10

3. Cervical spine is the most common site – F - lumbar spine; thoracic in Potts’s disease
4. With regards to Osteomyelitis – discitis of the spine, which is false: (TW)
5. The commonest organism is staph - T - staph is by far the most common organism; E Coli, Klebsiella & pseudomonas
6. Changes may be mimicked by Modic 1 changes on T1 and T2 - T
7. Cervical spine is the most common site – F - lumbar spine; thoracic in Potts’s disease
8. Involvement of multiple vertebral bodies is most likely TB - T – typically >15.Rapid loss of height favours pyogenic over TB - T - TB has slow collapse with disc preservation

Question 11

18.With regards to red marrow, which bones converts to fatty marrow firs

1. Spine
2. Ribs
3. Pelvis
4. Proximal humerus
5. Femoral diaphysis

Answer 11

5.Femoral diaphysis 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), 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 12

21. In MRI of the spine in normal adults, the following structures enhance with Gadolinium:
22. Bone Marrow
23. Disc fibrocartilage
24. Dorsal root ganglia
25. Spinal cord
26. Nerve roots

Answer 12

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. In MRI of the spine in normal adults, the following structures enhance with Gadolinium: (TW)
5. 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.
6. Disc fibrocartilage - F
7. Dorsal root ganglia - T - the DRG are void of a blood-nerve barrier and therefore will normally enhance after the injection of contrast.
8. Spinal cord - F - BBB
9. Nerve roots - F - Blood-nerve barrier - but probably not as well developed as in endonurial capillaries of peripheral nerve.

Question 13

23. Regarding MS, which is true?
24. 50% have plaques in cervical cord
25. Black hold is seen on T2 images
26. Lesions in the spinal cord are usually perpendicular to the long axis of the cord
27. Lesions more juxtacortical compared to those in small vessel disease

Answer 13

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. 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.
3. 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)
4. 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)
5. 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 14

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

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 14

true : 1, 3, 4, 5

Infection starts at endplate
In paediatric - starts a disc (due to vascular supply)Previous theory of spread via Batson’s plexus, this theory has been discounted.
Spread by 3 basic routes: haem, direct (ie trauma etc), contiguous from adjacent soft tissue infection. Haem most common cause.
Vertebral bone - highly vascular marrow with sluggish but high-volume blood flow via nutrient vessels. These vessels progressively develop characteristic “corkscrew” anatomy with aging which may predispose to hematogenous seeding (incidence of OM as a whole increases with age).
Segmental arteries supplying vertebrae - bifurcate to supply 2 adjacent end plates in contiguous vertebrae - so haem vertebral OM usually causes bone destruction in two adjacent vertebral bodies and their intervertebral disc. (UTD) Spinal tuberculosis is usually the result of hematogenous spread but can occur as direct extension from the lungs or subarachnoid space in cases of tuberculous meningitis. The most common site of involvement is the lower thoracic and upper lumbar spine
Spinal TB - infection usually starts in the ateroinferior aspect of cancellous vertebral body with inflammatory bone destruction and caseating necrosis. Can then spread behind ALL to involve adjacent vertebral body. In untreated or chronic cases, paraspinal, paravertebral, and psoas abscesses frequently occur. The intervertebral space remains relatively intact longer in tuberculosis than in pyogenic infections

Question 15

25. In regard to spinal meningiomas t/f
26. Bone invasion is a feature
27. Reactive bone sclerosis is a prominent feature
28. Tumour calcification is a prominent feature
29. They are typically isointense with cord on T1 and T2 weighted MR
30. Multiple spinal meningiomas suggest neurofibromatosis Type I

Answer 15

4 truespina meningioma- no calcification- no bony change- ONLY DURAL TAIL!!!

Meningioma of spine: 25-45% of all spine tumors; 2-3% of pediatric spinal tumors; 12% of all meningiomas Thoracic 82% > cervical spine on anterior cord near foramen magnum (2nd most common location). Site: intradural extramedullary 50%; entirely epidural; intradural + epidural.

Question 16

27.Ependymomas T/F

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 16

TRUE 1, 3, 4, 5
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
   * LW: cervical cord alone is most common isolated location, hence this answer favoured to be false.

– T - 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.

Question 17

28.Spinal Ependymomas

1. Myxopapillary ependymomas occur in the conus and filum terminale
2. Are cellular in the thoracic spine
3. Haemorrhage differentiates ependymomas from astrocytomas
4. Are calcified in more than 50%
5. Are a cause of non communicating hydrocephalus

Answer 17

true : 1, 2 Probably 3

28. Spinal Ependymomas (TW)
29. Myxopapillary ependymomas occur in the conus and filum terminale – T - (filum terminale ependymomas typically have a myxopapillary histology, and because of their location a reasonably specific diagnosis can be made)
30. Are cellular in the thoracic spine – T - cellular type most common. Typically cervical / cervicothoracic. Proximal cord ependymomas consist of more cellular variant.
31. Haemorrhage differentiates ependymomas from astrocytomas – F - presence of cysts and hemorrhage - favors ependymoma. Would favour, but ?not differentiate.
32. Are calcified in more than 50% – F - calcification rare compared with intracranial ependymomas
33. Are a cause of non communicating hydrocephalus – F - communicating - see previous question. 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 18

29. Syringomyelia is a recognised association of: t/f
30. Thoracic cord trauma
31. Meningeal metastases
32. Benign intracranial hypertension
33. Arachnoiditis
34. Arnold-Chiari malformation Type II

Answer 18

1,4, 5

29. Syringomyelia is a recognised association of: (TW)
30. Thoracic cord trauma - T - Chiari I malformation 41%, trauma 28%, neoplasm 15%, idiopathic 15%.
31. Meningeal metastases - F
32. Benign intracranial hypertension - F
33. Arachnoiditis - T - interrupted flow of CSF through the perivascular spaces of cord between subarachnoid space and central canal
34. 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)

Question 19

30. The following statements regarding congenital spinal abnormalities are true:
31. Diastematomyelia is typically associated with a congenital scoliosis
32. Dorsal dermal sinus most frequently occurs in the sacrococcygeal region
33. Caudal regression syndrome is associated with maternal diabetes mellitus
34. Neuroenteric cysts most commonly occur posterior to the spinal cord
35. Myelomeningocoele is associated with hydrocephalus in 70-90% of patients

Answer 19

true, 1,3, 5

30. The following statements regarding congenital spinal abnormalities are true: (TW)
31. 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%)
32. Dorsal dermal sinus most frequently occurs in the sacrococcygeal region – F - lumbosacral (60%), sacrococcygeal (1%), ventral (8%).
33. 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.
34. 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.
35. 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 20

32. Lumbar discs t/f
33. have a higher attenuation than cervical discs
34. 10% of disc herniations are calcified
35. most occur at L5/S1
36. MRI shows varied signal intensity of prolapsed discs
37. Central prolapse is most common

Answer 20

3.most occur at L5/S1 - T 4.MRI shows varied signal intensity of prolapsed discs - T

Question 21

36. An increased interpedicular distance occurs in: t/f
37. Achondroplasia
38. Meningocele
39. Diastematomyelia
40. Lipoma of the cord
41. AV Malformation of cord

Answer 21

2,3,4 true

36. An increased interpedicular distance occurs in: (GC)
37. 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.
38. 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%.
39. 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%.
40. 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.
41. AV Malformation of cord - F

Question 22

37. Causes of vertebral body fusion include:
38. TB
39. Brucellosis
40. Acromegaly
41. Gout
42. Ochronosis

Answer 22

1,2,5

37. Causes of vertebral body fusion include: (GC)
38. 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]
39. Brucellosis - T - ddx TB by presence of gas within disc, minimal paraspinal mass, no kyphosis, predilection for lower lumbar spine.
40. Acromegaly - F - excessive GH. Spinal changes: posterior scalloping (30%), anterior new bone, loss of disc space (weakened cartilage).
41. Gout - F - deranged purine metabolism. Spinal (and hip) involvement is rare: 1st MTP > ankles > heels > wrists > fingers > elbows; knees, shoulder, SIJ.
42. 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 23

38.Regarding MRI, which is false

:1.Sequestrated fragment is of low signal intensity on T2.

2. In young people a disc fragment has the same signal characteristics at the parent disc.
3. Loss of the intranuclear cleft is a sign of infection.
4. Endplate changes in degenerative disc disease are hyperintense on T1.
5. Recoil T2* imaging is better than T2 for disc degeneration.

Answer 23

5. Recoil T2* imaging is better than T2 for disc degeneration. F - decreased SI within the disc on T2WI, along with loss of the intranuclear cleft, appear to be the earliest signs of disc degeneration. These changes most probably result from dehydration. This decreased signal is not generally seen with GRE T2*, but only with spin-echo T2 images, and thus is a limitation that one needs to be aware of in the evaluation of GE images. [MRI Atlas of the Spine]
6. Regarding MRI, which is false: (GC)
7. Sequestrated fragment is of low signal intensity on T2. T - may be high (Kaplan states “often high”) or low on T2. It is low on T1, resembling the parent disc. The high SI on T2 is may be peripheral or diffuse (also seen on contrast-enhanced T1W images), caused by the inflammatory reaction within or around it.
8. In young people a disc fragment has the same signal characteristics at the parent disc. T - the signal intensity of a disc fragment is typically similar to that of the parent disc, but a long standing sequester that has undergone further degeneration or calcification may show marked signal alterations. [MRI atlas. M Weyreuther]
9. Loss of the intranuclear cleft is a sign of infection. T - a horizontally-oriented fibrous INC develops as an early manifestation of degeneration (low T2 line that divides the disc into upper and lower halves on sagittal imaging). The INC is lost in pyogenic spondylitis (may be preserved in Aspergillus infection). Diffuse low SI throughout the discs is a more advanced change of degeneration and aging. [Kaplan; MRI assessment of spine RG 2009]
10. Endplate changes in degenerative disc disease are hyperintense on T1. T - Modic type 2 = high T1, follows fat on T2 (fatty marrow conversion). Modic 1 = low T1, high T2 (oedema). Modic 3 = low T1, low T2 (sclerosis).
11. Recoil T2* imaging is better than T2 for disc degeneration. F - decreased SI within the disc on T2WI, along with loss of the intranuclear cleft, appear to be the earliest signs of disc degeneration. These changes most probably result from dehydration. This decreased signal is not generally seen with GRE T2*, but only with spin-echo T2 images, and thus is a limitation that one needs to be aware of in the evaluation of GE images. [MRI Atlas of the Spine] intranuclear cleft is a normal finding, mainly seen in young adults and reflecting the fibrous transformation of the gelatinous matrix of the nucleus pulposus.

Question 24

39.Spinal infection, T/F:

1. Commences at the anterior endplate.
2. Has a predilection for the posterior elements and facet joints.
3. A vacuum phenomena precludes disc infection.
4. Pyogenic spondylitis most commonly involves the lumbar spine & one spinal segment.
5. T1 is the most sensitive for detection of marrow involvement.

Answer 24

*LW:
Vacuum phenomena: although the vast majority of vacuum phenomena indicates degenerative disc disease / intervertebral osteochondrosis, or less commonly spondylsis deformans, it would not PRECLUDE / PREVENT infection. Radiopedia and some literature states the presence of intervertebral gas can be caused by infection. Thus option 3 favoured to be false.

true 1, 3, 4

39. Spinal infection, T/F: (GC)
40. Commences at the anterior endplate. T - because of its rich arterial supply. Then spreads to the rest of the vertebral body along the medullary spaces. Spreads through the disc space to the contiguous vertebrae.
41. Has a predilection for the posterior elements and facet joints. F - infection usually starts in the anterior portion of the vertebral body; affects endplates.
42. A vacuum phenomena precludes disc infection. T - although not universially assocd with osteonecrosis, the intervertebral vacuum cleft sign militates against the diagnosis of infection or malignancy. Note that the contents of the clefts may change with prolonged supine positioning (nitrogen-filled clefts fill with fluid that will be high SI on T2WI; mimics infection or other pathology).
43. Pyogenic spondylitis most commonly involves the lumbar spine & one spinal segment. T - the latter consists of 2 vertebral bodies and the intervening disc. Typically L3/4, L4/5, unusual above T9.
    * LW: Depends on the definition of spinal segment. Commonly involves two adjacent vertebral bodies, and can invovle multiple levels in upto 20%. Assuming spinal segment simply refers to vertebral body, then usually involves 2 vertebral bodies / segments, so then the last aspect of this question would be incorrect.

5.T1 is the most sensitive for detection of marrow involvement. F - T1 fat sat post gad. Infected marrow enhances diffusely post contrast.

Question 25

40.In degenerative disease of the cervical spine, T/F:

1. Neurocentral joints are more commonly involved in the upper cervical spine
2. Apophyseal joints are more commonly affected in the lower cervical spine
3. CT is as sensitive in the cervical spine as in use 1111-11bar spine
4. Plain films correlate poorly with clinical findings in people over 40
5. Ossification of the posterior longitudinal ligament is a feature of cervical spondylosis

Answer 25

true 2,4,5

40. In degenerative disease of the cervical spine, T/F:
41. Neurocentral joints are more commonly involved in the upper cervical spine F - aka uncovertebral joints. Spondylosis most common in lower C-spine (esp. C5/6, C6/7 - most mobile segments). Note that “lower C-spine” is defined as the intervertebral space at C2/3 to the intervertebral space at C7/T1. The C1 and C2 are rarely involved in producing radiculopathy.
42. Apophyseal joints are more commonly affected in the lower cervical spine T - loss of disc height, reversal of normal lordosis. Kyphosis due to spondylolitic changes leads to abnormal strain on the posterior facet joints.
43. CT is as sensitive in the cervical spine as in use 1111-11bar spine - ??not sure what this means.
44. Plain films correlate poorly with clinical findings in people over 40 T - Cervical spine films can demonstrate disc-space narrowing, osteophytosis, loss of cervical lordosis, uncovertebral joint hypertrophy, apophyseal joint osteoarthritis, and vertebral canal diameter. The presence of spondylotic radiographic changes in elderly patients is nearly universal (with a similar appearance of a C-spine film in a symptomatic patient and an asymptomatic patient) - hence requires clinical correlation.
45. Ossification of the posterior longitudinal ligament is a feature of cervical spondylosis T - OPLL can occur with cervical spondylosis. It is a hereditary disease found primarily in Asians; seen in 2% of the Asian population.[Spine, CM Bono; eMedicine]