Spinal Tumors — MCQs

10 questions

A 38-year-old woman presents with a history of backache. X-ray and MRI of the spine reveal collapse of the D12 vertebra with normal intervertebral disc space. The LEAST likely diagnosis is:

A middle aged female presents with prolonged history of back pain followed by slowly progressive weakness of both lower limbs, spasticity and recent onset difficulty in micturation. On neurological examination there is evidence of dorsal myelopathy. MRI scan of spine shows a well-defined mid-dorsal intradural homogenous contrast enhancing mass lesion. The likely diagnosis is:

Which is the treatment of choice for irradiation in Chordoma?

Epidural space lies between:

Investigation of choice for intramedullary SOL is -

Chordoma commonly involves which of the following locations?

Which radiotherapy technique involves the use of remote afterloading to deliver radiation directly to the tumor?

Column concept of spine stability was given by-

Most common benign tumor of bone:

Q10

A 50-year-old male with a history of chronic low back pain presents with new-onset bowel and bladder incontinence. What is the next best step in management?

Spinal Tumors Indian Medical PG Practice Questions and MCQs

Question 1: A 38-year-old woman presents with a history of backache. X-ray and MRI of the spine reveal collapse of the D12 vertebra with normal intervertebral disc space. The LEAST likely diagnosis is:

A. Tuberculosis
B. Metastasis
C. Multiple myeloma
D. Osteoporosis (Correct Answer)

Explanation: ***Osteoporosis*** - While osteoporosis can cause **vertebral collapse**, it typically results in a **wedging deformity** or uniform compression, usually without significantly affecting the intervertebral disc space [1]. - The patient's age (38 years old), while not precluding osteoporosis, makes it less likely to be the primary cause of a severe D12 collapse with normal disc space compared to other destructive processes. *Tuberculosis* - **Tuberculous spondylitis (Pott's disease)** commonly affects the vertebral body, often leading to its collapse (gibbus deformity) and subsequent **destruction of the intervertebral disc space** in later stages due to infection spread [2]. - The initial presentation with vertebral collapse and normal disc space followed by disc involvement is characteristic of tuberculous infection, making it a likely consideration. *Metastasis* - **Vertebral metastases** frequently cause osteolytic lesions that weaken the vertebral body, leading to collapse while often **sparing the intervertebral discs** initially due to their avascular nature [3]. - This presentation directly matches the description of D12 collapse with a normal disc space. *Multiple myeloma* - **Multiple myeloma** is a plasma cell malignancy that commonly causes **osteolytic lesions** in the spine, resulting in vertebral body collapse without significant involvement of the intervertebral discs. - This is a highly characteristic presentation for multiple myeloma, making it a strong differential for the given clinical and radiological findings.

Question 2: A middle aged female presents with prolonged history of back pain followed by slowly progressive weakness of both lower limbs, spasticity and recent onset difficulty in micturation. On neurological examination there is evidence of dorsal myelopathy. MRI scan of spine shows a well-defined mid-dorsal intradural homogenous contrast enhancing mass lesion. The likely diagnosis is:

A. Dermoid cyst
B. Epidermoid cyst
C. Spinal meningioma (Correct Answer)
D. Intradural Lipoma

Explanation: ***Spinal meningioma*** - This diagnosis fits the profile of a **middle-aged female** with a **slowly progressive dorsal myelopathy**, including **spasticity** and **urinary dysfunction**, as meningiomas are common in this demographic. - The MRI finding of a **well-defined, mid-dorsal, intradural, homogenous, contrast-enhancing mass** is highly characteristic of a spinal meningioma. *Dermoid cyst* - Dermoid cysts are typically **congenital lesions** and often present earlier in life with symptoms like **tethered cord syndrome** or related cutaneous stigmata. - While intradural, they usually present as **non-enhancing lesions** on MRI, unless there's an associated rupture or inflammatory reaction. *Epidermoid cyst* - Epidermoid cysts are also usually **congenital** and less common in the dorsal spine as primary lesions; their progression is often more indolent with less overt myelopathic signs early on. - On MRI, epidermoid cysts appear as **non-enhancing lesions** with signal characteristics similar to cerebrospinal fluid (CSF), distinguishing them from enhancing masses. *Intradural Lipoma* - Intradural lipomas are typically **congenital spinal lesions** often associated with **dysraphic states** and usually diagnosed in childhood. - They appear as **fat-containing lesions** on MRI, showing characteristic high signal intensity on T1-weighted images and signal suppression on fat-saturated sequences, and generally **do not show significant contrast enhancement**.

Question 3: Which is the treatment of choice for irradiation in Chordoma?

A. Protons (Correct Answer)
B. Electrons
C. Gamma radiation
D. 3D - CRT

Explanation: ***Protons*** - Proton therapy is the treatment of choice for **chordoma** due to its ability to deliver a high dose of radiation directly to the tumor while minimizing dose to surrounding healthy tissues. - This precision is critical for tumors located near **sensitive structures**, such as the brainstem, spinal cord, or optic nerves, common sites for chordomas. *Electrons* - **Electron therapy** is typically used for superficial tumors because electrons rapidly deposit their energy within the first few centimeters of tissue. - Chordomas are often deeply seated tumors, making electron therapy an unsuitable option for comprehensive treatment. *Gamma radiation* - **Gamma radiation**, as delivered by techniques like **Gamma Knife radiosurgery**, is primarily used for smaller, well-circumscribed intracranial lesions. - While precise, it may not be ideal for the larger, often irregularly shaped chordomas found in the skull base or sacrum, and it lacks the dose-sparing capabilities of proton beams at depth. *3D - CRT* - **3D Conformal Radiation Therapy (3D-CRT)** uses multiple beams to shape the radiation dose to the tumor, offering better conformity than conventional radiation. - However, compared to proton therapy, 3D-CRT still deposits a significant amount of radiation in tissues both distal and proximal to the tumor, leading to a higher risk of side effects, which is particularly concerning for chordomas given their proximity to critical structures.

Question 4: Epidural space lies between:

A. Dura and arachnoid
B. Pia and arachnoid
C. Dura and vertebral column (Correct Answer)
D. Pia mater and grey matter

Explanation: ***Dura and vertebral column*** - The **epidural space** is located between the dura mater and the surrounding vertebral column (specifically the **periosteum** lining the vertebral canal). - This space contains **fat, connective tissue**, and a **venous plexus**, acting as a protective cushion for the spinal cord. *Dura and arachnoid* - The space between the dura mater and the arachnoid mater is the **subdural space** [1]. - This is normally a **potential space** but can become a real space in pathological conditions like a subdural hematoma [1]. *Pia and arachnoid* - The space between the pia mater and the arachnoid mater is the **subarachnoid space** [1]. - This space normally contains **cerebrospinal fluid (CSF)** and blood vessels [1]. *Pia mater and grey matter* - The pia mater is directly apposed to the surface of the brain and spinal cord, including its **grey matter**. - There is no distinct "space" between the pia mater and the neural tissue it covers.

Question 5: Investigation of choice for intramedullary SOL is -

A. MRI (Correct Answer)
B. USG
C. CT
D. X-ray

Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the investigation of choice for intramedullary lesions due to its superior **soft tissue contrast** and ability to visualize the **spinal cord** parenchyma. - It provides detailed information on lesion size, location, and internal characteristics, which is crucial for diagnosis and surgical planning. *USG* - **Ultrasound (USG)** has limited utility for intramedullary lesions as a primary diagnostic tool because **bone impedes sound waves**, making it difficult to visualize structures within the spinal canal. - It might be used for neonatal spinal screening or intraoperative guidance, but not for definitive diagnosis of intramedullary lesions in adults. *CT* - **Computed Tomography (CT)** excels at visualizing **bone structures** and calcifications, but it provides less detailed information about soft tissue elements like the spinal cord compared to MRI. - While it can identify bony changes associated with intramedullary lesions, it is not the preferred initial imaging modality for characterizing the lesion itself. *X-ray* - **X-rays** provide basic imaging of bone but offer essentially **no visualization of soft tissues** such as the spinal cord or intramedullary lesions. - They are primarily used to identify gross bony abnormalities like fractures or severe degenerative changes, not for subtle intraspinal pathologies.

Question 6: Chordoma commonly involves which of the following locations?

A. Clivus and sacrum (Correct Answer)
B. Dorsal spine
C. Lumbar spine
D. Cervical spine

Explanation: ***Clivus and sacrum*** - Chordomas are rare malignant bone tumors derived from remnants of the **notochord**, which primarily occur at the ends of the axial skeleton. - The most common sites are the **sacrococcygeal region (lower spine)** and the **clivus (base of the skull)**, accounting for approximately 50-60% and 30-40% of cases, respectively. *Dorsal spine* - While chordomas can occur anywhere along the axial skeleton, involvement of the **dorsal (thoracic) spine** is much less common compared to the clivus and sacrum. - This region represents a smaller percentage of overall chordoma cases. *Lumbar spine* - Similar to the dorsal spine, the **lumbar spine** is an atypical location for chordomas, with a lower incidence than the sacrum and clivus. - Although it is part of the axial skeleton, it is not one of the predilection sites for these tumors. *Cervical spine* - **Cervical spine** involvement in chordomas is rare, occurring in less than 10% of cases. - Its incidence is significantly lower compared to the clival or sacrococcygeal regions.

Question 7: Which radiotherapy technique involves the use of remote afterloading to deliver radiation directly to the tumor?

A. Brachytherapy (Correct Answer)
B. External Beam Radiotherapy
C. Stereotactic Radiotherapy
D. Proton Beam Radiotherapy

Explanation: ***Correct: Brachytherapy*** - **Remote afterloading** is a hallmark of modern brachytherapy, where radioactive sources are automatically advanced into catheters placed within or near the tumor. - This technique allows for the delivery of a **high dose of radiation directly to the tumor** while sparing surrounding healthy tissues. - Examples include **intracavitary** (cervical cancer), **interstitial** (prostate cancer), and **intraluminal** (esophageal cancer) brachytherapy. *Incorrect: External Beam Radiotherapy* - This technique involves delivering radiation from a machine **outside the body** to target a tumor. - It does not involve the direct placement of radioactive sources within the patient or the use of **remote afterloading**. *Incorrect: Stereotactic Radiotherapy* - While a precise form of external beam radiotherapy using focused beams, it still involves an **external source** of radiation. - It does not utilize internal radioactive sources or **afterloading techniques**. *Incorrect: Proton Beam Radiotherapy* - This is an advanced form of external beam radiotherapy that uses **protons instead of photons** to deliver radiation with high precision. - It does not involve the placement of radioactive sources within the patient or the use of **remote afterloading**.

Question 8: Column concept of spine stability was given by-

A. Denis (Correct Answer)
B. Wilson
C. Todd
D. Frenkel

Explanation: ***Denis*** - The **column concept of spinal stability** was proposed by Denis, dividing the spine into three columns: anterior, middle, and posterior. - This model is crucial for classifying **spinal fractures** and determining their stability. *Wilson* - Wilson's name is associated with several medical concepts, but not directly with the **column concept of spinal stability**. - For example, **Wilson's disease** is a genetic disorder of copper metabolism. *Todd* - Todd is known for **Todd's paralysis**, a transient post-seizure neurological deficit. - He did not contribute to the foundational theories of **spinal biomechanics** or stability. *Frenkel* - Frenkel is associated with the **Frenkel exercises**, used in the rehabilitation of **tabes dorsalis** to improve coordination. - He did not propose any significant theories on **spinal stability** or its anatomical columns.

Question 9: Most common benign tumor of bone:

A. Bone cyst
B. Osteochondroma (Correct Answer)
C. Osteoblastoma
D. Chordoma

Explanation: ***Osteochondroma*** - **Osteochondroma** is the **most common benign bone tumor**, accounting for approximately 35-40% of all benign bone tumors [2]. - It arises from the growth plate and is characterized by a cartilage cap covering a bony stalk, typically affecting the **metaphysis** of long bones [1], [2]. *Bone cyst* - **Unicameral bone cysts** (simple bone cysts) and aneurysmal bone cysts are common benign bone lesions, but they are not true tumors. - They are typically fluid-filled lesions that can weaken the bone, predisposing to **pathological fractures**. *Osteoblastoma* - **Osteoblastoma** is a rare benign bone tumor, much less common than osteochondroma [3]. - It is characterized by the production of **osteoid** and **woven bone** and often causes pain due to its richly innervated nature [3]. *Chordoma* - **Chordoma** is a rare, malignant bone tumor, not benign. - It arises from remnants of the **notochord** and typically occurs at the sacrococcygeal region, skull base, or vertebral column. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1202. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1200.

Question 10: A 50-year-old male with a history of chronic low back pain presents with new-onset bowel and bladder incontinence. What is the next best step in management?

A. Conservative management with NSAIDs
B. Bed rest
C. Urgent MRI of the spine (Correct Answer)
D. Physical therapy

Explanation: ***Urgent MRI of the spine*** - The new onset of **bowel and bladder incontinence** in a patient with chronic low back pain is highly suggestive of **cauda equina syndrome**. This is a surgical emergency. - An **urgent MRI** is crucial to confirm the diagnosis and identify the level of compression, guiding immediate surgical decompression to prevent permanent neurological deficits. *Conservative management with NSAIDs* - This approach is appropriate for routine, uncomplicated low back pain, but it is entirely inadequate for a **neurological emergency** like potential cauda equina syndrome. - Delaying definitive diagnosis and treatment in such cases can lead to irreversible neurological damage, including chronic incontinence and paralysis. *Bed rest* - While bed rest might be recommended for acute exacerbations of certain types of back pain, it is not a primary treatment for neurologic emergencies and will not resolve the underlying compression causing **cauda equina syndrome**. - Prolonged bed rest can also lead to complications like deconditioning and venous thromboembolism, and it would waste critical time for diagnosis and intervention. *Physical therapy* - Physical therapy is a cornerstone of management for chronic low back pain and for rehabilitation after an acute event once stability is achieved. - However, in cases of suspected **cauda equina syndrome**, physical therapy is contraindicated as an initial step because it does not address the acute spinal cord or nerve root compression and may worsen the condition or delay necessary surgical intervention.

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