Spine Imaging: Trauma and Degenerative Disease — MCQs
What is the investigation of choice for diagnosing a stress fracture?
A 75-year-old female has chronic backache. X-ray of the spine is shown. What is the most likely diagnosis?
What is the investigation of choice in a patient with traumatic paraplegia?
Identify the condition shown in the image:
After chronic use of steroids severe pain in right hip with immobility is due to
Spine MRI shows 'pencil-sharpened' vertebral bodies and 'H-shaped' vertebrae on T1-weighted images. Most likely diagnosis?
A patient with a history of chronic ear infection now presents with manifestations, including headache and vomiting. A CT brain image is shown. What is the most probable diagnosis?
Time of Flight technique is employed in —
What is the primary imaging modality used for diagnosing urethral trauma?
A patient presents with a suspected cervical spine injury following an accident. What is the first step in management?
Spine Imaging: Trauma and Degenerative Disease Indian Medical PG Practice Questions and MCQs
Question 1: What is the investigation of choice for diagnosing a stress fracture?
- A. X-ray
- B. CT scan
- C. MRI (Correct Answer)
- D. Bone scan
Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** is the most sensitive and specific imaging modality for diagnosing **stress fractures**, especially in their early stages. - It can detect **bone marrow edema** and **periosteal reactions** indicative of stress injury before cortical changes are visible on plain radiographs. *X-ray* - **X-rays** are often the initial investigation, but they have low sensitivity for **stress fractures** in the early stages as bone changes may not be apparent for several weeks. - A positive X-ray for stress fracture typically shows a **sclerotic line** or **periosteal reaction**, but this indicates a more advanced injury. *CT scan* - **CT scans** provide excellent detail of **cortical bone** and can detect subtle fractures not seen on X-rays. - While more sensitive than X-rays, CT has **higher radiation exposure** and is generally less sensitive than MRI for early detection of **bone marrow edema** associated with stress injuries. *Bone scan* - **Bone scans** (scintigraphy) are highly sensitive for detecting increased **osteoblastic activity** associated with stress fractures. - However, they are **less specific** as various conditions can cause increased uptake, and they do not provide detailed anatomical information, making MRI superior for definitive diagnosis and staging.
Question 2: 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 3: What is the investigation of choice in a patient with traumatic paraplegia?
- A. Myelography
- B. CT scan
- C. MRI scan (Correct Answer)
- D. Plain X-ray
Explanation: ***MRI scan*** - An **MRI scan** provides superior imaging of **soft tissues**, including the spinal cord, nerves, and ligaments, which are crucial for assessing damage in **traumatic paraplegia**. - It is essential for detecting **spinal cord compression**, hemorrhage, edema, and ligamentous injuries that may not be visible on other imaging modalities. *Plain X-ray* - A **plain X-ray** primarily visualizes bony structures and can detect major **fractures or dislocations** but offers limited information about the spinal cord or soft tissue damage. - It may miss subtle bony injuries and provides no information on **spinal cord integrity**, which is critical in paraplegia. *Myelography* - **Myelography** involves injecting contrast dye into the spinal canal and then performing X-rays or CT scans, which is an **invasive procedure** with potential risks. - While it can demonstrate **spinal cord compression** indirectly, it has largely been replaced by MRI due to its invasiveness and MRI's direct visualization capabilities. *CT scan* - A **CT scan** is excellent for evaluating **bony injuries**, such as vertebral fractures and alignment, with good detail. - However, it is less effective than MRI for directly visualizing the **spinal cord itself** and assessing soft tissue damage, which is paramount in paraplegia.
Question 4: 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 5: After chronic use of steroids severe pain in right hip with immobility is due to
- A. Avascular necrosis (Correct Answer)
- B. Perthes disease
- C. Hip dislocation
- D. Osteoarthritis
Explanation: ***Avascular necrosis*** - Chronic **steroid use** is a major risk factor for avascular necrosis (AVN), particularly affecting the **femoral head** of the hip. - Reduced blood supply leads to bone death, resulting in severe pain and impaired mobility. *Perthes disease* - This is a condition of idiopathic **avascular necrosis of the femoral head** occurring in **children**, primarily between ages 4-10. - It is not associated with steroid use and typically presents in a different age group. *Hip dislocation* - Hip dislocation presents with **acute, severe pain** and an inability to bear weight or move the hip, often due to significant trauma. - While it causes immobility, it is an **acute traumatic event** rather than a chronic consequence of steroid use. *Osteoarthritis* - Osteoarthritis is a degenerative joint disease characterized by **cartilage breakdown** and joint pain that typically **worsens with activity** and improves with rest. - While chronic hip pain can be due to osteoarthritis, its direct link to steroid use for severe pain and immobility as described is less prominent than AVN.
Question 6: Spine MRI shows 'pencil-sharpened' vertebral bodies and 'H-shaped' vertebrae on T1-weighted images. Most likely diagnosis?
- A. Thalassemia
- B. Osteopetrosis
- C. Sickle cell disease (Correct Answer)
- D. Paget's disease
Explanation: ***Sickle cell disease*** - **Sickle cell disease** can lead to vertebral body changes due to **bone infarction** and **hyperplasia of hematopoietic marrow**, causing central depression and characteristic 'H-shaped' or 'pencil-sharpened' vertebrae. - The abnormal hemoglobin in sickle cell anemia causes red blood cells to stiffen and form a crescent or "sickle" shape, leading to a host of debilitating symptoms and early death. *Thalassemia* - **Thalassemia** can cause widespread marrow expansion leading to generalized osteopenia and widened medullary spaces, but typically does not result in the focal 'H-shaped' vertebral changes seen with infarction. - While it also causes anemia and bone changes, the specific vertebral findings described are not characteristic of thalassemia. *Osteopetrosis* - **Osteopetrosis** is characterized by **increased bone density** and brittle bones, often described as a "stone bone" appearance. - This condition leads to thickened, sclerotic bones and does not produce the 'H-shaped' or 'pencil-sharpened' vertebral deformities. *Paget's disease* - **Paget's disease** is characterized by disorganized bone remodeling, leading to bone enlargement and deformity with a characteristic **"cotton wool" appearance** on imaging. - While it affects vertebrae, it typically results in cortical thickening and coarsened trabeculae, not the specific 'H-shaped' deformity.
Question 7: A patient with a history of chronic ear infection now presents with manifestations, including headache and vomiting. A CT brain image is shown. What is the most probable diagnosis?
- A. Meningitis
- B. Extradural Abscess
- C. Cerebral Abscess
- D. Temporal lobe Abscess (Correct Answer)
Explanation: ***Temporal lobe Abscess*** - The CT scan shows a **ring-enhancing lesion** with significant surrounding edema, which is characteristic of a **brain abscess**. - Given the history of a **chronic ear infection**, the temporal lobe is a common site for bacterial spread from the mastoid air cells or middle ear. *Meningitis* - Meningitis involves inflammation of the **meninges** and typically presents with diffuse changes on imaging, such as sulcal effacement or leptomeningeal enhancement, rather than a focal, encapsulated lesion. - While it can cause headache and vomiting, the CT image does not show findings typical of meningitis. *Extradural Abscess* - An extradural (or epidural) abscess is located **between the dura mater and the skull bone**. - It would typically appear as a collection outside the brain parenchyma, potentially causing mass effect but distinct from an intraparenchymal lesion seen in the image. *Cerebral Abscess* - The image does show a **cerebral abscess**, but this option is less specific than "Temporal lobe abscess." - The question asks for the **most probable diagnosis**, and combining the imaging findings with the patient's history of ear infection points to a specific location within the cerebrum.
Question 8: Time of Flight technique is employed in —
- A. Spiral CT
- B. MR imaging (Correct Answer)
- C. Digital radiography
- D. CT angiography
Explanation: ***MR imaging*** - The **Time of Flight (TOF)** technique is a type of **magnetic resonance angiography (MRA)** that exploits the phenomenon of **flow-related enhancement** of fresh, unsaturated blood entering an imaging slice. - It is used to visualize blood flow without the need for an external contrast agent, making it particularly useful for assessing vessels in the brain and neck. *Spiral CT* - **Spiral CT** (helical CT) involves continuous data acquisition as the patient moves through the gantry, creating a spiral path of X-ray projection data. - While it has revolutionised CT angiography, it does not employ the Time of Flight principle, which is specific to MR imaging. *Digital radiography* - **Digital radiography** uses X-rays to create images, which are captured by digital sensors rather than photographic film. - This technique primarily focuses on structural imaging and does not involve the physical principles (like spin physics of protons in a magnetic field) necessary for Time of Flight applications. *CT angiography* - **CT angiography** uses **iodinated contrast material** injected intravenously to visualize blood vessels with high resolution using X-rays. - Unlike Time of Flight MRA, it relies on the contrast enhancement of flowing blood with an exogenous agent, not on the intrinsic properties of blood flow within a magnetic field.
Question 9: What is the primary imaging modality used for diagnosing urethral trauma?
- A. Ascending urethrogram (Correct Answer)
- B. Descending urethrogram
- C. USG
- D. CT scan
Explanation: ***Ascending urethrogram*** - An **ascending urethrogram** (also known as a retrograde urethrogram) is the **gold standard** for diagnosing urethral trauma. - It involves injecting contrast material directly into the urethra to visualize its integrity and identify any extravasation, strictures, or ruptures. *Descending urethrogram* - A descending urethrogram (or voiding cystourethrogram) is primarily used to evaluate the **bladder and urethra during urination**, often for vesicoureteral reflux or bladder neck dysfunction. - It is not the primary diagnostic tool for acute urethral trauma, as it requires the patient to void, which might be painful or difficult with an injured urethra. *USG* - **Ultrasound** (USG) can be used to assess the presence of peri-urethral hematomas or fluid collections but is generally **not sufficient to definitively diagnose urethral integrity** or the exact location and extent of a tear. - Its utility in urethral trauma is limited compared to direct contrast imaging of the urethra. *CT scan* - A **CT scan** of the pelvis can identify associated injuries, such as **pelvic fractures** or hematomas, that often accompany urethral trauma. - However, it is **less sensitive for direct visualization of the urethral lumen** and diagnosing the extent of a urethral injury compared to an ascending urethrogram.
Question 10: A patient presents with a suspected cervical spine injury following an accident. What is the first step in management?
- A. perform imaging studies
- B. administer oxygen
- C. stabilize the cervical spine (Correct Answer)
- D. log roll the patient
Explanation: ***stabilize the cervical spine*** - In any suspected cervical spine injury, the **first and most critical step is to stabilize the cervical spine** to prevent further neurological damage. This is achieved through manual inline stabilization, followed by a **rigid cervical collar** and placement on a backboard. - This immediate stabilization is paramount before any other assessments or interventions that could potentially worsen the injury. *perform imaging studies* - While imaging studies (e.g., X-ray, CT scan) are crucial for diagnosing the extent of cervical spine injury, they should only be performed **after the spine has been adequately stabilized**. - Performing imaging prior to stabilization risks **further displacement** of vertebrae and spinal cord injury. *administer oxygen* - Administering oxygen is an important step in **maintaining adequate oxygenation** and is part of initial resuscitation, but it does not take priority over cervical spine stabilization in a trauma setting. - **Airway, Breathing, Circulation (ABC)** management should always incorporate cervical spine protection. *log roll the patient* - **Log rolling** is a technique used to move a patient with a suspected spinal injury, but it must be performed **only after the cervical spine is stabilized** and with sufficient personnel to ensure coordinated movement. - Log rolling is not the first step in management; rather, it is a technique for patient assessment and transfer once initial stabilization is achieved.
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