Spine pathology + bone tumours

Question 1

L5 radiculopathy

Answer 1

Weakness of hip abduction
Weakness in foot and big toe dorsiflexion - foot drop
Sensory loss of dorsum of foot
+ve sciatic nerve stretch test

Question 2

Sciatic neuropathy

Answer 2

Loss of ankle jerk and plantar response

Loss of knee flexion and power below knee

Question 3

L3 root compression

Answer 3

Sensory loss over anterior thigh

Weak quadriceps - Reduced knee extension
Weak hip flexion and hip adduction

Absent knee jerk test

Positive femoral stretch test

Question 4

L4 nerve root compression

Answer 4

Sensory loss of anterior aspect of knee

Weak quads - Reduced knee extension

Absent knee reflex

Positive femoral stretch test

Question 5

S1 nerve root compression

Answer 5

Sensory loss of posterolateral aspect of leg and lateral foot and sole of foot

Weak plantar flexion
Reduced ankle reflex
+ve sciatic nerve stretch test

Question 6

RF for primary bone cancers

Answer 6

RB1 and p53 mutation - osteosarcoma in children

TSC1/2 mutation - chondroma during childhood

Exposure to alkylating agents in chemotherapy and radiotherpay

Pagets disease and fibrous dysplasia

Question 7

Which bone tumours show soap bubble appearance on Xray

Answer 7

Giant cell tumours

Question 8

Bone tumour causing Codman’s triangle or sunburst pattern on Xray

Answer 8

Osteosarcoma

Question 9

Bone tumour causing onion skin pattern on Xray

Answer 9

Ewing’s sarcoma

Question 10

Bone tumour causing lytic lesions with calcification, endosteal scalloping and cortical remodelling on Xray

Answer 10

Chondrosarcoma

Question 11

Pott’s disease

Answer 11

Vertebral TB
Back pain and neurological features
Low grade fever
MRI gold standard

Question 12

L4 sciatica distribution of pain

Answer 12

Anterior thigh
Anterior knee
Medial leg

Question 13

L5 sciatica distribution of pain

Answer 13

Lateral thigh
Lateral leg
Dorsum of foot

Question 14

S1 sciatica

Answer 14

Posterior thigh
Posterior leg
Heel
Sole of foot

Question 15

Sciatic nerve roots

Answer 15

L4 - S3

Question 16

Femoral nerve roots

Answer 16

L2 - L4

Question 17

Obturator nerve roots

Answer 17

L2 - L4 anterior divisions

Question 18

Common bone metastasis

Answer 18

Prostate 
Breast 
Kidney 
Thyroid 
Lung

Question 19

Symptoms of bone tumours

Answer 19

Pain not associated with movement
Worse at night
Pathological fractures - without trauma

Question 20

Osteoid osteoma summary, age, presentation, Mx

Answer 20

Benign 
Arise from osteoblasts 
10 - 20 yrs old 
Males > females 
Metaphysis of long bones 

Symptoms:

• progressive localised pain
• worse at night
• Better with NSAIDs
• can have localised swelling, tenderness and limping

Mx:

• serial X-ray - every 4 - 6 months
• surgical resection - if severe pain

Question 21

Osteochondroma summary, age, presentation, Mx

Answer 21

Benign
Outgrowth from metaphysis covered with a cartilaginous cap
10 - 20 yrs old

Normally asymptomatic and slow growing
Can cause deformity of impinge on nerves if large

Ix:
- X-ray - pedunculated growth on metaphysis

Mx:

• conservative management with serial X-ray - 4 - 6 months
• if symptomatic and large - surgical resection

Question 22

Chondroma summary, age, presentation, Mx

Answer 22

Benign
Arise from chondroblasts - within medulla

20-50 years old

Affecting the long bones of the hands, femur, and humerus

Symptomatic
Pathological fractures

Ix:
Xray - well circumscribed oval lucency with intact cortex

Mx:
- conservative - observation if asymptomatic and small

• large or symptomatic chondromas may require removal with curettage and bone grafting

Question 23

Giant Cell Tumour summary, age, presentation, Mx

Answer 23

Benign
Arise from the multinucleated giant cells and stromal cells - affects epiphysis of long bones
20-30 years old

Symptoms:

• pain
• swelling
• limitation of joint movement

Ix:
Xray - eccentric lytic area, giving a “soap bubble” appearance

Mx:
Surgical resection - may require bone grafting or reconstruction

Question 24

Most common malignant primary bone tumour

Answer 24

Osteosarcoma

Question 25

Osteosarcoma

Answer 25

Malignant Found in metaphysis of the distal femur or proximal tibia Either at 10-14 years or in those >65yrs RF: Paget's disease Symptoms: - localised constant pain and a tender soft tissue mass may be palpable Ix: - Xray - medullary and cortical bone destruction + periosteal reactions- Codman’s triangle” or as a “sunburst pattern” - Tissue biopsy Mx: - aggressive surgical resection with systemic chemotherapy

Question 26

Where does osteosarcoma metastasis to

Answer 26

Lung and bone

Question 27

Ewing’s Sarcoma

Answer 27

Paediatric malignancy M>F Arise from primitive poorly differentiated neuroectodermal cells - commonly affect the diaphysis of long bones Symptoms: - painful and enlarging mass - tenderness and warmth Ix: Xray - lytic lesion with periosteal reactions -producing layers of reactive bone - “onion skin” appearance Mx: - neoadjuvant chemotherapy followed by surgical excision - radiotherapy if unresectable

Question 28

Chondrosarcoma

Answer 28

Malignant tumours of the cartilage Onset is 40-60 yo Affects axial skeleton - especially pelvis, shoulder, and ribs Symptoms: - painful and enlarging mass Ix: Xray - lytic lesions with calcification, cortical remodelling, and endosteal scalloping Mx: Low grade lesions- intralesional curettage Intermediate- and high-grade lesions -wide en-bloc local excision

Question 29

Radiological Features of Bone Tumours

Answer 29

Benign - sharp and well-defined, lacking soft tissue involvement and no cortical destruction Malignant - poorly defined with rough borders, involving soft tissues and have cortical destruction

Question 30

Radiculopathy

Answer 30

Conduction block in the axons of a spinal nerve or its roots - motor axons - weakness - sensory axons - paraesthesia

Question 31

Radicular pain

Answer 31

pain from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion

Question 32

Causes of radiculopathy

Answer 32

Compression due to: - Intervertebral disc prolapse - Degenerative diseases of the spine - Fracture - Malignancy - Infection - Extradural abscess, osteomyelitis, Pott's disease (TB) or herpes zoster

Question 33

Mx of radiculopathy

Answer 33

Amitriptyline Pregabalin and gabapentin as alternatives. Muscle spasms -benzodiazepines (often diazepam) or baclofen Physio

Question 34

Lasègue Test

Answer 34

Straight leg raise - assess for disc herniation With the patient lying down on their back, the examiner lifts the patient’s leg while the knee is straight. The ankle can be dorsiflexed and / or the cervical spine flexed for further assessment.

Question 35

Degenerative disc disease mx

Answer 35

Pain relief - NDAIDs or co - codamol Activity - encouraging motility Physiotherapy - strengthening the core

Question 36

Jefferson Fracture

Answer 36

Atlas C1 burst fracture Due to axial loading of cervical spine

Question 37

Hangman’s Fracture

Answer 37

Fracture through the pars interarticularis of C2 (axis) bilaterally Due to cervical hyperextension and distraction

Question 38

Odontoid Peg Fractures

Answer 38

Most common in older patients Low-impact injuries and neck pain Can be fatal, especially with significant displacement of the odontoid; those who survive can have no neurology

Question 39

Investigations for cervical fractures

Answer 39

CT scan | MRI scan - for children

Question 40

Management of cervical spine fractures

Answer 40

ATLS 3 point C spine immobilisation Analgesia and admit Stable: - rigid color and halo vests Unstable: - Posterior fixation - pedicle scres and rods - Fusion - across the injured segment of the spine to the uninjured segments above and below, with or without decompression of the vertebral canal.