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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5211_Библиотеки_им_академика_М_И_Перельмана
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Paul Rushton and Niall Eames
from the scoliosis. At presentation, radiographs showed
a right thoracic curve measuring 25°. A PA standing
whole spine radiograph taken today (Figure 11.2).
E. The curve is not likely to progress now as
she is skeletally mature
12. You are counselling the patient and family
about the condition. They would like to know
the likely outcome if left untreated.
You explain that without treatment, compared with someone unaffected, she is more
likely to experience which of the following?
A. Have back pain and depression
B. Have concerns about cosmesis
C. Have reduced life expectancy
D. Struggle with activities of daily living such
as prolonged sitting
E. Struggle with childbirth and have an
increased need for caesarean section
13. The patient opts for surgical management by
way of posterior instrumented correction and
fusion. Bending films are obtained, demonstrating the main thoracic curve reduces to 40°. A
left-sided proximal thoracic curve measures 15°
and lumbar curve 20° on the left bending film.
Surgery should aim to correct and fuse which
of the following?
A. Lumbar and proximal thoracic curves
B. Main thoracic and lumbar curves
C. Main thoracic and proximal thoracic curves
D. Main thoracic curve
E. Proximal thoracic, main thoracic and
lumbar curves
Figure 11.2 PA standing whole spine radiograph
11. What is likely to happen regarding her potential curve progression?
A. Curve resolution may occur if the rib verte-
bral angle difference (RVAD) is <20°
B. Given the size of the curve, it is likely to
progress rapidly
C. Her curve is likely to progress slowly during
adult life
D. She has significant spinal growth remaining,
over which time her curve may worsen
224
14. You are seeing a 10-year-old boy referred to
you for recurrent falls. He has a complex background first noted on prenatal screening and
had cardiac surgery in the first few weeks of life.
He sees a paediatric orthopaedic surgeon about
his hips, but they do not think the falls are
related. He denies any pain, but his mother says
he has seemed quite clumsy over the past few
months. He has a flattened facial profile and
nose. He looks to have a straight spine on
examination but will not allow detailed neurological examination today.
The most indicated action at this point is
which of the following?
A. Cervical spine flexion/extension views
B. CT of cervical spine
C. MRI scan of whole neuroaxis
Spine I Structured SBA
D. Observation, bring back in 4 weeks to allow
complete neurological examination
E. Standing whole spine X-rays
15. You are seeing a 15-year-old girl in clinic with a
background of quadriplegic spastic cerebral palsy,
GMFCS 5, referred from a community paediatrician. Carers report problems with seating and care
due to her spinal shape alongside poor nutrition
and recurrent chest infections. She is seated
poorly with signs of costo-pelvic impingement
but with some curve flexibility on elevation. A
sitting radiograph is shown in Figure 11.3.
D. Paediatric gastroenterology review
E. Posterior correction and instrumented fusion
T3–pelvis
16. A 14-year-old girl presents with low back pain
and symptoms affecting her right leg. A standing
radiograph is shown in Figure 11.4.
Her symptoms are most likely to include which
of the following?
Figure 11.4 Standing
lateral lumbar
spine radiograph
Figure 11.3 AP whole spine sitting radiograph
Which of the following is the most appropriate
action to take at this time?
A. Anterior release and posterior correction and
instrumented fusion T3–pelvis
B. Moulded brace
C. Observation; further appointment in 12
months
A. Radicular pain felt onto the dorsomedial
aspect of the foot
B. Radicular pain felt over the medial aspect of
the leg
C. Radicular pain over the lateral aspect of the
foot
D. Weakness in ankle plantar flexion
E. Weakness in tibialis anterior
17. A 14-year-old boy who bowls for his county attends
with low back pain for the past 3 months. X-rays
demonstrate a grade 2 lytic spondylolisthesis.
A step is most likely to be felt between the
spinous processes of which of the following?
A. L1 and L2
B. L2 and L3
C. L3 and L4
D. L4 and L5
E. L5 and S1
225
Paul Rushton and Niall Eames
18. A 16-year-old dancer returns to clinic suffering
with low back pain and severe bilateral radicular
leg pain. X-rays demonstrate no change to her
known grade 2 lytic spondylolisthesis at the lumbosacral junction. She previously responded well
to repeated bilateral nerve root and pars blocks
and physiotherapy, but symptoms have returned.
Pain limits her daily activities despite suitable
oral analgesia. She is requesting a more permanent treatment.
The most indicated treatment is which of the
following?
A. In situ L4–S1 instrumented fusion with L4/5
decompression
B. In situ instrumented fusion of L5/S1 with
decompression L5 nerve roots in their foramina
C. In situ uninstrumented L5–S1 fusion
D. L4– S1 instrumented fusion with resection L5
E. Reduction of spondylolisthesis with instru-
mented fusion L5–S1 and decompression L5
nerve roots in their foramina
19. A 15-year-old, previously well boy presents with
back pain and a temperature of 37.8°C. He has
paraspinal muscle spasm on examination, but
neurological examination is normal. His CRP is
83 and WCC 17. MRI scans with axial through
the level of interest are shown in Figure 11.5.
Figure 11.5 (a) Sagittal T2, (b) sagittal
T1 with gadolinium enhancement and (c)
axial T2 at level of interest MRI images
lumbar spine
226
Spine I Structured SBA
The most suitable next step in management is
which of the following?
A. Administration of IV antibiotics
B. Application of thoraco-lumbo-sacral orthosis
C. Biopsy
D. Blood cultures
E. Surgical debridement of the epidural abscess
20. A 9-year-old boy presents with back pain and
weight loss. He is ambulant and neurologically
intact. Blood WCC is normal. A whole spine
MRI shows enhancement of T10 and T11 vertebral bodies with preservation of adjacent disks
with a small paraspinal abscess. On standing Xrays there is 15° kyphosis across the affected area
with some collapse of the T10 and T11 vertebrae
but is otherwise well aligned. A biopsy shows
Langhans giant cells with cultures pending.
The most appropriate treatment at this time is
which of the following?
A. Costotransversectomy, debridement with
allograft anterior reconstruction and pedicle
screw posterior instrumentation
B. Decompression via thoracic laminectomy
C. Nine months of antimicrobials
D. Thoracotomy, radical debridement and
anterior reconstruction with rib autograft
and instrumentation
E. Three months of flucloxacillin and rifampi-
cin, pending cultures
21. A 14-year-old, 20-month post-menarchal girl
presents to your spinal clinic with the condition
shown in Figure 11.6. She is mildly concerned
regarding her current shape and but has
minimal pain. Her neurological examination is
unremarkable.
The most appropriate intervention at this
time is:
A. Anterior release and posterior instrumented
correction
B. MRI whole spine
C. Observation clinical and radiographic follow
up in 6–12 months
D. Posterior instrumented correction
E. Referral for brace
Figure 11.6 Whole spine PA and lateral radiographs
227
Paul Rushton and Niall Eames
22. You decide to perform an open anterior release
on a 16-year-old with large (110°) and stiff but
otherwise typical late onset idiopathic scoliosis
with apex at the T9 level.
How would you position the patient and over
which rib would you make your incision?
A. Left Lateral (Right side up), 7th rib
B. Left Lateral (Right side up), 9th rib
C. Right Lateral (Left side up), 7th rib
D. Right Lateral (Left side up), 9th rib
E. Supine, 9th rib
23. You are reviewing a 5-year-old boy with known
spinal abnormality shown in Figure 11.7. He has
received no treatment to date but further
imaging excludes associated abnormalities. You
note progressive deformity over the previous 24
months with kyphosis measuring 60°.
What is the most appropriate action at this
point?
A. Anterior release and posterior instrumented
fusion
B. Application of hyperextension brace
C. Insertion of conventional growing rods
D. Short segment posterior instrumented
fusion/resection of abnormality
E. Shorten follow-up interval with review in 2
months
Degenerative
24. A 60-year-old man has a fall from a standing
height and is admitted via ambulance to the ED.
He complains of cervicothoracic back pain. He is
otherwise well aside from a history of ankylosing
spondylitis. On examination, he is in discomfort
but neurologically intact. Supine radiographs of
the cervical, thoracic and lumbar spine are
obtained that do not demonstrate a fracture.
The most appropriate action is which of the
following?
A. Mobilise with physiotherapy
B. MRI scan in the morning
C. Obtain swimmer’s view
D. Spinal precautions, CT scan
E. Standing (weight bearing) X-rays
25. A 65-year-old male presents with low back pain
and pain radiating down the leg to the dorsum
of the right foot.
From the list given, what is the most likely
diagnosis?
A. L4/5 central canal stenosis
B. L4/5 foraminal disc prolapse
C. L4/5 foraminal stenosis
D. L4/5 lateral recess stenosis
E. L4/5 posterolateral disc prolapse
Figure 11.7 Thoracolumbar lateral radiograph (left) and CT sagittal reconstruction of same region (right)
228
Spine I Structured SBA
26. A 67-year-old otherwise well male presents with
pain down the medial aspect of both shins. MRI
confirms that he has bilateral lateral recess stenosis in keeping with his presentation. His standing X-ray is shown in Figure 11.8. He has
undergone appropriate conservative treatment
involving a 6-week complete relief following
bilateral nerve root blocks. His pain has
returned, and he is requesting treatment.
Which of the following is the most appropriate treatment?
Figure 11.8
Standing lateral
lumbar spine
radiograph
A. Disc osteophyte complex
B. Inferior articular process of L4
C. Ligamentum flavum
D. Pedicle of L5
E. Superior articular process of L5
28. A 67-year-old man presents suffering with left
leg pain. He reports diffuse pain over much of
the lower leg and foot without clear stenotic
symptoms. He has no specific neurological deficit and good distal pulses. An MRI demonstrates multilevel pathology, including bilateral
L4 foraminal stenosis, a grade 1 degenerative
spondylolisthesis at L4/5 with associated lateral
recess stenosis and broad-based left L5/S1
impinging on the traversing nerve root.
To guidetargeted surgery, the most appropriate
diagnostic injection is which of the following?
A. Bilateral L3/4, L4/5, L5/S1 facet joint medial
branch blocks
B. Caudal epidural
C. L5/S1 and L4/5 discography
D. Left L5 nerve root block +/– further
injections
E. Lumbar epidural
A. Continued conservative treatment, which
will afford similar outcomes to surgery over
the next few years
B. L3/4 decompression
C. L3/4 decompression and instrumented pos-
terolateral fusion
D. L4/5 decompression
E. L4/5 decompression and instrumente d pos-
terolateral fusion
27. A 65-year-old retired anatomist presents with
radicular leg pain into the dorsum of his right
foot. An MRI is undertaken showing lateral
recess stenosis that accounts for his symptoms.
You go on to describe the pathology.
In his case, the nerve root in question is most
likely being compressed by which of the
following?
29. A 48-year-old female presents with back and
bilateral leg pain. Her standing radiograph is
shown in Figure 11.9. On recent MRI scan,
central stenosis, lateral recess stenosis and right
sided facet joint cyst are contributing to nerve
root compression. There are L4/5 facet joint
Figure 11.9
Standing lateral
lumbar spine
radiograph
229
Paul Rushton and Niall Eames
effusions and the joints are aligned in the sagittal plane.
Following confirmatory diagnostic injections,
the most appropriate treatment is most likely
which of the following?
A. L4/5 instrumented fusion and decompres-
sion central canal and L4 foramen
B. L4/5 instrumented fusion and decompres-
sion central canal and L4 nerve roots in
lateral recesses
C. L4/5 instrumented fusion and decompres-
sion central canal and L5 nerve roots in
lateral recesses
D. Decompression central canal and L4 nerve
roots in lateral recesses
E. Decompression central canal and L5 nerve
roots in lateral recesses
30. A 40-year-old man presents with right shoulder
and neck pain. On examination, he has weakness on Jobe’s/empty can test. Following exclusion of shoulder pathology, MRI imaging of his
neck is undertaken, demonstrating nerve root
compression concordant with his examination
findings.
The nerve in question leaves the spine between
the pedicles of which of the following?
A. C2 and C3
B. C3 and C4
C. C4 and C5
D. C5 and C6
E. C6 and C7
31. A 36-year-old labourer presents with numbness
over the right little finger. On examination, he
has a globally reduced range of motion of his
cervical spine, isolated altered sensation over
the volar aspect of his right little finger but no
wasting or weakness.
Which investigation is the most appropriate?
A. Cervical spine radiograph
B. CT wrist and hand
C. MRI cervical spine
D. MRI wrist
E. Neurophysiological studies
32. A 56-year-old plasterer presents with a 3-month
history of neck pain. He feels the pain in the mid
cervical region in the midline and it is worse
after a long day’s work. He is otherwise well.
He has a reduced range of cervical motion which
causes him pain but has no upper or lower limb
symptoms or signs. An MRI had been arranged
by his GP and is shown in Figure 11.10.
Figure 11.10 (a) Sagittal T2 and (b) axial T2 at C5/6 MRI images of cervical spine
230
Spine I Structured SBA
The most appropriate action at this point is
which of the following?
A. Bilateral C6 nerve root blocks
B. C4/5 and C5/6 cervical disc replacement
C. C4/5 and C5/6 anterior cervical decompres-
sion and fusion
D. Onward referral to local pain service
E. Reassurance, analgesia and mobilisation
33. A 65-year-old otherwise well Caucasian female pre-
sents with right brachialgia. On questioning, she has
noticed increasing difficulty with her sewing and
some unsteadiness on her feet. Examination findings include an inverted supinator reflex.
Which pathology underlying this presentation
is most likely?
A. Atlantoaxial instability (AAI)
B. Calcified central thoracic disc prolapse
C. Cervical disc/osteophyte complex
D. Neoplasia
E. Ossification of the posterior longitudinal
ligament (OPLL)
34. You are undertaking the approach for an anterior lumbar interbody fusion at L4/5. While
mobilising the vessels, you encounter significant
haemorrhage.
An injury to which vessel(s) has most likely
occurred?
A. Ilio-lumbar vein
B. Left common iliac artery
C. Left common iliac vein
D. Median sacral vessels
E. Right common iliac vein
35. You are seeing a 35-year-old who has had left leg
pain to the lateral aspect of his foot for the past 8
weeks. He has no weakness or bladder/bowel
symptoms. A recent MRI is shown in Figure
11.11 with axi al at the L5/S1 level.
In counselling him about the treatment options
at this point, you explain to him which of the
following?
A. As the pain has been going on for 8 weeks, he
has failed conservative management, and
microdiscectomy surgery is the best option
B. Continued conservative treatment will likely
lead to reduced back pain at 1 year compared
with surgery
C. Continued conservative treatment will likely
result in similar resolution of leg pain at 1
year as surgery
Figure 11.11 (a) Sagittal T2 and (b) axial T2 at L5/S1 level MRI images lumbar spine
231
Paul Rushton and Niall Eames
D. Recurrence of sciatica in the year following
surgery, necessitating revision surgery is
about 10%
E. Surgery will reduce the overall disability he
suffers over the next year
36. A 70-year-old female with a history of rheumatoid arthritis presents with decreasing hand function and is now struggling to feed herself.
Romberg’s test is positive on examination, with
upgoing plantars and weak upper and lower
limbs to power 4/5. Radiographs are undertaken
with a posterior atlantodental interval (PADI) of
10mm on flexion view, Ranawat’sC1–2 index
measures 15mm, the tip of the dens is below
the McRae line and there is no subluxation in
the lower cervical spine.
Which treatment is most indicated?
A. C1–C2 fusion
B. Foramen magnum decompression
C. Occiput–C2 fusion
D. Occiput–C5 posterior decompression and
fusion
E. Odontoidectomy
37. The plane developed during the approach for
an anterior cervical discectomy and fusion is
best described as between which of the
following?
A. Carotid sheath and pretracheal fascia
B. Carotid sheath and sternocleidomastoid
C. Deep investing layer of cervical fascia and the
prevertebral fascia
D. Sternocleidomastoid and platysma
E. Sternocleidomastoid and prevertebral fascia
38. You review a 45-year-old diabetic man on the
medical ward. He has been under the care of the
medical team for 1 week and has been treated for
a presumed pneumonia with oral antibiotics,
over which time the blood cultures taken on
admission have grown Staphylococcus aureus.
While on the ward he is complaining of back
pain, prompting a whole spine MRI, with the
thoracolumbar aspect of this scan shown in
Figure 11.12, with axial throug h the level of
Figure 11.12 (a) Sagittal T2 and (b) axial T2 at level of interest MRI images thoracolumbar aspect
232
Spine I Structured SBA
interest. He has no neurological deficit and is
ambulating around the ward with temperature
of 37.4°C.
What is the most appropriate action at this
time?
A. Anterior decompression with debridement of
disc and bone and reconstruction
B. IV antibiotics
C. Percutaneous biopsy and antibiotics based on
culture sensitivities
D. Percutaneous posterior stabilisation and IV
antibiotics
E. Posterior decompression and discectomy
39. You are asked to see a 26-year-old man with a
3-month history of back pain and weight loss.
He has normal neurology and is freely ambulating around the ward. A Mantoux test is
positive. An MRI scan shows pathology at the
T8 level.
What are the MRI changes most likely to be?
A. Destruction of the intervertebral disc with
adjacent bone loss and an enhancing collection anteriorly
B. Enhancement in the vertebral body with pre-
servation of the adjacent discs and elevation
of the anterior longitudinal lig ament
C. Enhancing lesions to the vertebral body with
similar changes at multiple levels; dark on T1,
bright on T2
D. Gross T8 bone loss with a 40° focal kyphosis
with tenting of the cord and associated
myelomalacia
E. Lesion within the right lamina enhancing
brightly on T2
40. A 34-year-old female presents to the emergency
department with a 5-day history of bilateral sciatica and a 24-hour history of episodes of bladder
incontinence. She has a history of LBP for some
years.
Which of the following statements correctly
describes her evaluation?
A. 24 hours from onset of symptoms to surgery
is a critical cut-off for bladder function
B. A poor correlation exists between clin ical
finding and MRI findings
C. A post void residual (PVR) bladder volume of
125ml is highly significant and establishes a
diagnosis of cauda equina syndrome with a
98% positive predictive value
D. An MRI examination is not required if PVR
bladder volume is more than 550ml
E. PR examination is a sensitive and specific test
of cauda equina function, as the nerves supplying anal function tolerate pressure poorly
41. A 62-year-old man presents with a thoracic disc
protrusion. These disc protrusions:
Which statement best describes his
presentation?
A. Are less common in Scheuermann’s disease
B. Present with sensory symptoms rather than
motor symptoms usually
C. The herniation is calcified in 10% of cases
D. When operated on an anterior approach or a
costo-transversectomy is considered lower
risk for neurological deterioration than
laminectomy
E. Will most commonly occur between T3 and T7
42. When consenting a patient for spinal surgery,
which statement best describes information
patients need to know?
A. After posterior cervical decompression, the
risk of a c5 nerve palsy is 5%, with a poor
prognosis for recovery
B. Following anterior cervical discectomy and
fusion, the incidence of dysphagia is 30%
C. Paralysis is a very rare complication of
lumbar surgery and does not need to be
mentioned
D. The incidence of dural tears following lumbar
discectomy is 7%
E. The overall complication rate for lumbar
decompression is around 12%
43. A 45-year-old is referred by the medical team.
Having presented 3 days ago with a 48h history
of fever, low back pain, mild bilateral leg pain but
no urinary symptoms. On admission he had a
CRP of 250 and blood cultures were taken with
no growth currently. The medical team commenced antibiotics on admission and arranged
a whole spine MRI scan, the salient lumbar
aspects of which are shown in Figure 11.13.
Reviewing him you note he has a temperature
of 38.0 and normal power L2-S1 and altered
233
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