Spine Imaging — MCQs
Which imaging modality is LEAST useful in the initial diagnosis of stress fractures?
A patient developed paraplegia. On routine examination and X-ray it was found that there are osteoblastic lesions in his spine. What is the MOST probable diagnosis?
Identify the condition shown in the image:
Jefferson fracture is -
Dennis stability concept is based on which of the following?
A 75-year-old female has chronic backache. X-ray of the spine is shown. What is the most likely diagnosis?
Following are listed as (SpA) spondyloarthritis features except
Scotty dog sign is seen in:
A man presents with back pain following a road traffic accident (RTA). There is no history of neurological deficit. An X-ray of the spine is done. What is the diagnosis based on the image?
Which of the following is least useful for diagnosing spondylolisthesis?
Spine Imaging Indian Medical PG Practice Questions and MCQs
Question 1: Which imaging modality is LEAST useful in the initial diagnosis of stress fractures?
- A. MRI
- B. Bone scan
- C. X ray
- D. CT (Correct Answer)
Explanation: ***Correct: CT*** - While **CT** can show bony details, it is **less sensitive** than MRI or bone scan for early stress fractures, which often involve subtle marrow edema or periosteal reaction - Its primary role is usually in defining **fracture geometry** or evaluating **fracture healing**, not initial detection - **CT is rarely used as a first-line imaging modality** for suspected stress fractures *Incorrect: MRI* - **MRI** is highly sensitive for **stress fractures**, detecting early changes such as **marrow edema** and **periosteal reaction** before they are visible on X-ray - It is considered the **gold standard** for confirming a stress fracture when initial X-rays are negative - This is one of the MOST useful modalities, not the least *Incorrect: Bone scan* - **Bone scintigraphy** (bone scan) is very sensitive for **stress fractures**, as it detects increased **osteoblastic activity** at the site of injury - It can identify stress fractures long before they are visible on plain radiographs, showing a focal area of increased radiotracer uptake - This is highly useful for initial diagnosis, not the least useful *Incorrect: X-ray* - **Plain radiographs (X-rays)** are often the **initial imaging modality** for suspected stress fractures due to availability and cost - However, they have **low sensitivity in the early stages** - early stress fractures may appear normal on X-ray - Visible signs such as **sclerosis, periosteal reaction**, or a **fracture line** only develop several weeks after symptom onset - Despite low sensitivity, X-ray is still more commonly used for initial evaluation than CT
Question 2: A patient developed paraplegia. On routine examination and X-ray it was found that there are osteoblastic lesions in his spine. What is the MOST probable diagnosis?
- A. Breast Ca.
- B. Carcinoma thyroid
- C. Pancreatic Ca.
- D. Ca. Prostate (Correct Answer)
Explanation: ***Ca. Prostate*** - **Prostate cancer** has a strong predilection for metastasizing to bone and typically produces **osteoblastic lesions** (new bone formation) in the spine [2]. - The presence of **paraplegia** suggests spinal cord compression due to these metastatic lesions [1]. *Breast Ca.* - While **breast cancer** frequently metastasizes to bone (commonly spine, pelvis, ribs, skull), it typically causes **osteolytic lesions** (bone destruction), though mixed lesions can occur. - Paraplegia can result from breast cancer metastases but the primary lesion type is usually osteolytic. *Carcinoma thyroid* - **Thyroid cancer** metastases to bone are rare and generally lead to **osteolytic lesions**, not osteoblastic. - Although it can cause spinal cord compression, the characteristic osteoblastic appearance is not typical for thyroid cancer. *Pancreatic Ca.* - **Pancreatic cancer** rarely metastasizes to bone, and when it does, the lesions are almost exclusively **osteolytic**. - Therefore, it is highly unlikely to be the cause of osteoblastic spinal lesions and subsequent paraplegia.
Question 3: Identify the condition shown in the image:
- A. Renal osteodystrophy
- B. Spondylolisthesis
- C. Tuberculosis (TB)
- D. Spondylolysis (Correct Answer)
Explanation: ***Spondylolysis*** * The image shows a **break in the pars interarticularis** of a vertebra, indicated by the arrow, which is characteristic of spondylolysis. * This condition is a **stress fracture** or defect in the pars interarticularis, a bony segment connecting the superior and inferior articular facets. *Renal osteodystrophy* * Renal osteodystrophy refers to a spectrum of **bone abnormalities** that occur in chronic kidney disease, not a specific vertebral fracture pattern. * It typically involves features such as **osteomalacia**, **osteitis fibrosa cystica**, or **osteoporosis**, which are not directly depicted as a fracture in this image. *Spondylolisthesis* * Spondylolisthesis is the **anterior slippage** of one vertebral body over another, which can be caused by bilateral spondylolysis but is not directly shown as a slip in this specific image. * The image distinctly highlights the **fracture line** itself, rather than the displacement of the vertebral body. *Tuberculosis (TB)* * Spinal tuberculosis (Pott's disease) typically presents with **destruction of vertebral bodies**, disc space narrowing, and often a **paravertebral abscess**. * The image does not show these features; instead, it demonstrates a clear **bony defect** in the pars interarticularis.
Question 4: Jefferson fracture is -
- A. Fracture of any cervical vertebra
- B. Fracture of axis
- C. Fracture of spinous process of C7
- D. Fracture of atlas (Correct Answer)
Explanation: ***Fracture of atlas*** - A **Jefferson fracture** specifically refers to a **burst fracture** of the **C1 vertebra (atlas)**, caused by a compressive force on the head. - This type of fracture often involves **four separate fractures** within the anterior and posterior arches of the atlas. *Fracture of any cervical vertebra* - This is a too broad a statement; while the atlas is a cervical vertebra, a Jefferson fracture is a specific type affecting only C1. - Cervical spine fractures can involve various vertebrae (C1-C7) and different fracture patterns, not all of which are Jefferson fractures. *Fracture of axis* - The **axis** is the **C2 vertebra**, and its characteristic fractures include a **dens fracture** or a **hangman's fracture**, which involve different mechanisms and anatomical locations than a Jefferson fracture. - Injury to C2 can cause different neurological deficits compared to C1. *Fracture of spinous process of C7* - A fracture of the spinous process of C7 is known as a **clay-shoveler's fracture** and is typically an avulsion injury, not a burst fracture from axial compression. - This type of fracture usually results from forceful neck flexion, leading to avulsion of the spinous process.
Question 5: Dennis stability concept is based on which of the following?
- A. 4 columns
- B. 3 columns (Correct Answer)
- C. 5 columns
- D. 2 columns
Explanation: ***3 columns*** - The **Denis classification** system for spinal stability divides the vertebra into three conceptual columns: **anterior**, **middle**, and **posterior**. - This three-column model helps in assessing the **stability of spinal fractures** and guiding treatment decisions. *4 columns* - The four-column concept is **not standard** for Denis classification; it would overcomplicate the established three-column model. - Adding a fourth column lacks the **clinical utility** and widespread acceptance of the Denis system. *5 columns* - A five-column system is **not recognized** in the standard Denis classification of spinal stability. - Such a detailed breakdown would be **excessive** and not provide additional practical information for assessing stability. *2 columns* - The two-column concept, often seen in older classifications like **Holdsworth classification**, predates Denis's work and was found to be **less comprehensive** for assessing spinal stability. - It does not account for the critical stabilizing role of the **middle column** in spinal fractures.
Question 6: A 75-year-old female has chronic backache. X-ray of the spine is shown. What is the most likely diagnosis?
- A. Osteoporosis (Correct Answer)
- B. Spondylodiscitis
- C. Pott's spine
- D. Spondylolisthesis
Explanation: ***Osteoporosis*** - The X-ray shows diffuse **osteopenia** (reduced bone density) and **vertebral compression fractures**, particularly visible in the lateral view, which are characteristic findings in elderly patients with osteoporosis and chronic backache. - The vertebral bodies appear **demineralized** and some exhibit a loss of height, suggesting collapse due to weakened bone structure. *Spondylodiscitis* - This condition involves **inflammation of the vertebral body and adjacent intervertebral disc**, typically showing **erosions** of the vertebral endplates and **narrowing of the disc space** on X-ray, which are not clearly evident here as the primary issue. - While it can cause back pain, the dominant finding on this X-ray is widespread bone density loss and fractures, rather than localized infection-related changes. *Pott's spine* - Pott's spine (**tuberculous spondylitis**) is a form of osteomyelitis that causes **destruction of vertebral bodies** and adjacent discs, often leading to a **gibbus deformity** (sharp posterior angulation of the spine). - The X-ray does not show extensive vertebral destruction, paraspinal abscess formation, or typical kyphotic deformity associated with Pott's spine. *Spondylolisthesis* - Spondylolisthesis is characterized by the **forward slippage of one vertebral body over another**, often due to a defect in the pars interarticularis. - While there may be some degenerative changes, there is no clear evidence of significant anterior translation of a vertebral body on the lateral X-ray that would indicate spondylolisthesis.
Question 7: Following are listed as (SpA) spondyloarthritis features except
- A. Cervical sprain (Correct Answer)
- B. Dactylitis
- C. Enthesitis
- D. HLA B27
Explanation: **Cervical sprain** - A **cervical sprain** is an injury to the ligaments in the neck, typically caused by trauma or sudden movements, and is not a defining characteristic or feature of spondyloarthritis. - Sprains involve the stretching or tearing of soft tissues, whereas spondyloarthritis is a group of **inflammatory conditions** primarily affecting the spine and peripheral joints. *Dactylitis* - **Dactylitis**, or "sausage digits," refers to the **inflammation of an entire digit** (finger or toe) and is a characteristic feature of spondyloarthritis, particularly **psoriatic arthritis** and **reactive arthritis** [1]. - It results from inflammation of both the joints and the tendons within the affected digit [1]. *Enthesitis* - **Enthesitis** is the **inflammation of the entheses**, which are the sites where tendons or ligaments insert into bone [1]. - This is a hallmark feature of spondyloarthritis, commonly seen at sites like the **Achilles tendon insertion** or the plantar fascia [1]. *HLA B27* - **HLA-B27** is a human leukocyte antigen that is strongly associated with spondyloarthritis [1]. - Its presence is a significant genetic marker found in a high percentage of patients with **ankylosing spondylitis** and other forms of spondyloarthritis [1].
Question 8: Scotty dog sign is seen in:
- A. Spondylolysis (Correct Answer)
- B. Fracture femur
- C. Sarcoidosis
- D. Osteosarcoma
Explanation: ***Spondylolysis*** - The **Scotty dog sign** is a classic radiographic finding on an **oblique lumbar spine X-ray** indicating a defect in the pars interarticularis. - This defect, known as **spondylolysis**, causes the "neck" of the Scotty dog to appear broken or wearing a collar. *Fracture femur* - **Femur fractures** are typically identified by discontinuity of the cortical bone and soft tissue swelling, often visualized on **AP and lateral views of the thigh/hip**. - No specific "Scotty dog" appearance is associated with femur fractures, as this sign relates to the **lumbar spine**. *Sarcoidosis* - **Sarcoidosis** is a multi-system inflammatory disease primarily affecting the lungs and lymph nodes, with characteristic **non-caseating granulomas**. - Radiological findings typically include **hilar lymphadenopathy** and pulmonary infiltrates, not a bony defect like the Scotty dog sign. *Osteosarcoma* - **Osteosarcoma** is a primary malignant bone tumor often presenting with a **sunburst pattern** or **Codman triangle** on X-ray. - It primarily affects the metaphysis of long bones and does not produce the specific bony defect seen in the pars interarticularis.
Question 9: A man presents with back pain following a road traffic accident (RTA). There is no history of neurological deficit. An X-ray of the spine is done. What is the diagnosis based on the image?
- A. Spinous process fracture (Correct Answer)
- B. Chance fracture
- C. Compression fracture
- D. Fracture of base of vertebrae
Explanation: ***Spinous process fracture*** - The X-ray image reveals a **fracture of the spinous process** of one of the cervical vertebrae, characterized by a visible discontinuity or separation of this posterior bony projection. - This type of fracture, often caused by direct trauma or forceful hyperextension/hyperflexion, typically presents with localized back pain but often **without neurological deficit** as the spinal canal generally remains intact. *Chance fracture* - A **Chance fracture** (or seatbelt fracture) is a horizontal fracture of a vertebral body, usually in the thoracolumbar region, often caused by distractional forces (e.g., flexion over a seatbelt). - It involves all three columns of the spine (anterior, middle, and posterior) and is not seen in the cervical spine X-ray provided. *Compression fracture* - A **compression fracture** is characterized by the collapse of the vertebral body, often resulting in a wedge shape. - This typically appears as reduced height of the anterior vertebral body on an X-ray, which is not the primary finding in the image. *Fracture of base of vertebrae* - A **fracture at the base of the vertebrae** is a non-specific term; specific vertebral fractures are categorized based on the part of the vertebra affected (e.g., vertebral body, pedicle, lamina, spinous process). - The image distinctly shows a fracture in the **spinous process**, not the main body or base of the vertebra.
Question 10: Which of the following is least useful for diagnosing spondylolisthesis?
- A. X-ray spine lateral view
- B. MRI
- C. CT scan
- D. X-ray spine AP view (Correct Answer)
Explanation: ***X-ray spine AP view*** - An **AP (Anterior-Posterior) view** of the spine is least useful for diagnosing spondylolisthesis because it does not adequately demonstrate the **forward slippage** of one vertebra over another. - This view primarily visualizes the spine in the **coronal plane**, making it difficult to assess the **sagittal displacement** characteristic of spondylolisthesis. *X-ray spine lateral view* - A **lateral view** of the spine is highly useful as it directly shows the **sagittal alignment** and can clearly demonstrate the **anterior displacement** of a vertebral body. - It is often the **initial imaging modality** for suspecting and classifying spondylolisthesis severity. *MRI* - **MRI** is excellent for evaluating **soft tissue structures**, such as the spinal cord, nerve roots, and intervertebral discs, which can be compressed or damaged by spondylolisthesis. - While it can visualize the slippage, it is usually reserved for assessing **neurological compromise** or if surgical planning requires detailed soft tissue information. *CT scan* - **CT scans** provide detailed **bony anatomy** and are highly effective in visualizing the pars interarticularis defects (spondylolysis) often associated with spondylolisthesis. - It offers superior detail compared to plain X-rays for assessing the **extent of bone displacement** and associated degenerative changes.
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