Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5211_Библиотеки_им_академика_М_И_Перельмана
.pdf
Paul Rushton and Niall Eames
Figure 11.13 Lumbar T2 sagittal with T2 axial through level indicated by blue line
sensation in L4-S1 bilaterally. A post-micturition
bladder scan is 25ml. His CRP today is 245.
What is the most appropriate action at this time?
A. Change to broader spectrum antimicrobials.
B. CT chest/abdomen/pelvis
C. Echocardiogram
D. Open spinal decompression/drainage and
sampling
E. Spinal decompression/drainage and sampling
with instrumented fusion
Trauma
44. Which of the following spinal cord injuries
carries the best prognosis?
A. Ipsilateral weakness with contralateral loss of
pain and temperature
B. Loss of motor and all sensory function bilat-
erally below level of injury aside the bulbocavernosus reflex
C. Loss of proprioception with preserved power
and pinprick sensation bilaterally
D. Predominantly motor dysfunction dispropor-
tionately affecting the upper limbs vs legs
E. Weakness and numbness in all four limbs
with preserved proprioception bilaterally
45. A 28-year-old male is involved in a high-speed
RTA, sustaining a cervical spine fracture dislocation, treated with prompt reduction and stabilisation. At 48 hours later he is examined and found to
have a present bulbocavernosus reflex. He can flex
his elbows against gravity and extend his wrists
actively when gravityis eliminated but has no motor
function in more caudal levels. He has no peri-anal
sensation, but he has normal sensation over the
lateralaspectofhisarmsandforearms.
What is his ASIA grade and neurological level
of injury?
A. AC5
B. AC6
C. BC5
D. BC6
E. EC5
46. A 26-year-old is involved in a high-energy car
accident in which he drove into a tree, sustaining
bilateral femoral shaft fractures and a traumatic
brain injury. A CT is undertaken.
Which of the following is suggestive of an occipitocervical dissociation (OCD)?
A. Avulsion fractures of occipital condyles
B. Basion–axial interval (BAI) 10mm
C. Basion–dens interval (BDI) 5mm
D. Occipital condyle fracture extending into the
base of skull
E. Powers ratio 0.9
47. A 60-year-old sustained an injury to the right
side of C1 while diving into a swimming pool.
He is neurologically intact. A CT scan is undertaken and shown in Figure 11.14.
This suggests which of the following?
A. Transverse ligament is disrupted and C1–C2
fusion is indicated
234
Spine I Structured SBA
Figure 11.14 (a) Axial CT and (b)
coronal reconstruction
B. Transverse ligament is disrupted and C1–C2
fusion is NOT indicated
C. Transverse ligament is disrupted and
occiput–C2 fusion is indicated
D. Transverse ligament is NOT disrupted and
C1–C2 fusion is indicated
E. Transverse ligament is NO T disrupted and
C1–C2 fusion is NOT indicated
48. A 34-year-old amateur rock climber falls 3m
from a boulder. He complains of isolated
neck pain but is neurologically intact. A CT scan
shows a minimally displaced fracture of the
odontoid peg extending into the body of the axis
bone.
The most suitable treatment at this time is
which of the following?
A. Anterior lag screw fixation
B. C1–2 fusion with transarticular screws
C. Posterior Goel-Harms type C1–2 fusion
D. Rigid cervical orthosis
E. Soft collar and mobilisation once pain settles
49. An 83-year-old man falls while cutting the roses
in his allotment, sustaining an isolated neck
injury. He is otherwise well and neurologically
intact. His CT scan is shown in Figure 11.15.
Compared with treatment of this injury with a
halo vest, treatment in a semi-rigid collar is
more likely to be associated with which of the
following?
A. Death
B. Failure to complete treatment
C. Neurological deterioration
D. Non-union
E. Pneumonia
Figure 11.15 (a) Sagittal and (b) coronal CT reconstructions
235
Paul Rushton and Niall Eames
50. A 65-year-old male is involved in a high-energy
motorcycle accident. He is agitated and confused
in A&E but appears to have weakness in his
hands and lower limbs to a power of 3/5. A CT
scan of his head shows frontal cerebral contusions and the sagittal and parasagittal spine CT
images are shown in Figure 11.16. He has no
other injuries and his anaesthetists say it is safe
to go to theatre if needed.
The most appropriate management at this time
is which of the following?
A. Administration of methylprednis olone
B. Application of Gardner–Wells tongs and
gradual reduction with cervical traction
C. Application of halo jacket
D. MRI scan
E. Transfer to theatre for reduction and stabilisation
with C6/7 ACDF +/– posterior instrumentation
51. A 27-year-old male is involved in a high-speed
motorcycle a ccident. On arrival to the ED, he is
agitated and trying to remove his mask and lines
and has a GCS of 8. He is promptly intubated. He
is haemodynamically stable following fluid resuscitation but has obvious lower open fractures.
The only injuries on a formally reported traum a
pan-CT scan are an intracranial extradural
haematoma, AP compression grade 2 pelvic fracture and displaced transverse process fractures of
L1–L4. You are consulted regarding spinal stability before transfer for long bone stabilisation and
neurosurgical intervention.
The most appropriate action at this time is
which of the following?
A. Cervical collar and blocks can be removed,
but the patient requires logrolling for the
lumbar spine injury
Figure 11.16 (a)–(c) Sagittal and parasagittal CT reconstructions
236
Spine I Structured SBA
B. Full cervical protection with collar, sandbags
and tape should be maintained until a time
when clinical examination can be performed,
as he may have an occult unstable injury
C. Full cervical protection with collar, sandbags
and tape should be maintained until an MRI
scan is undertaken
D. He should be logrolled, and spine clinically
examined to assess for swelling or bogginess
that may suggest ligamentous disruption
E. The patient can be considered to have a
‘stable’ spine. All cervical protection can be
removed, and the patient positioned carefully
in theatre
Questions 52–53 Stem:
A 25-year-old male is involved in a head-on collision in a
car going 70mph. On examination, he has swelling and
local tenderness over the T12– L1 area but has no
neurological deficit. CT scan images are shown in Figure
11.17 with the axial through the level of the injury.
When measured formally, the angulation between the
superior end plate of T12 and the inferior end plate L2 is
16°.
52. The best description of the nature of this injury
is which of the following?
B. Bony flexion distraction injury (Chance)
A. Burst fracture
C. Compression fracture
D. Osseoligamentous flexion distraction injury
E. Translational/rotational injury
53. What is the most appropr iate management at
this time?
A. Non-operative; standing X-rays, mobilisation
+/– TLSO brace
B. Surgery; anterior corpectomy L1 and recon-
struction with short segment posterior fixation T12–L2
C. Surgery; long segment posterior fixation T11–L3
D. Surgery; short segment fixation T12–L2/L3
E. Surgery; short segment fixation T12–L2/L3
with fusion
Figure 11.17 (a) Sagittal CT reconstruction and (b) axial through injured level
237
Paul Rushton and Niall Eames
Figure 11.18 (a) Sagittal CT reconstruction thoracolumbar spine and (b) axial cut at area of interest
Questions 54–55 Stem:
A 58-year-old farmer falls from his tractor. Following a
full trauma workup, he is found to have a fracture of L2
with paraesthesia in his right thigh but has no other
neurological signs. He has some slight tenderness
paraspinally over the lumbar spine but no focal
midline tenderness or swelling. CT scans are shown in
Figure 11.18.
D. MRI scan
E. Short segment posterior stabilisation +/–
decompression
56. You are referred a 43-year-old involved in a
high-speed RTA. She is maintaining her
airway and haemodynamically stable. There
are no obvious limb or head injuries. She
has MRC 0/5 in L1-S1 myotomes but some sen-
54. From the available information, the best
description of the nature of this injury is which
of the following?
A. Bony flexion distraction injury (Chance)
B. Burst fracture
C. Compression fracture
D. Osseoligamentous flexion distraction injury
E. Translational/rotational injury
sation peri-anally. A CT scan is undertaken
(Figure 11.19). The general surgeons identify a
pancreatic injury and duodenal perforation on
this imaging. Her last lactate is 1.2 and base
excess 1.
Discussing your thoughts with the general surgeon on call, what would you feel the most
appropriate next step is?
A. Administration of high-dose methyl-
55. The most appropriate management at this
point is which of the following?
A. Anterior corpectomy and reconstruction +/–
posterior instrumentation
B. Bed rest
C. Mobilisation and standing radiographs when
pain allows
prednisolone
B. Laparotomy for management of general sur-
gical injury
C. MRI scan whole spine
D. Posterior instrumented fusion with long
construct
E. Transfer to ITU for further resu scitation
238
Figure 11.19 Sagittal and coronal CT reconstructions
Spine I Structured SBA
57. A 67-year-old man presents to the ED after a
minor fall 5 days ago. His back is sore between
his shoulder blades. He has a history of ankylosing spondylitis. An X-ray of his spine shows a
‘bamboo spine’, but no fracture.
Which of the following statements best
describes how he should be managed?
A. A CT scan should be performed as it will
exclude a fracture and should be performed
as an emergency
B. HLA B27 positive patients have a better clinical
response to tumour necrosis factor inhibitors
and an earlier age at diagnosis compared with
HLA B27 negative patients
C. If a fracture is diagnosed and surgery is
deemed to be necessary, the patient should
be nursed flat with full spinal immobilisation
until the surgery which will probably require
3 levels fixation above and 3 levels below the
fracture
D. If a fracture is diagnosed, it probably can be
treated conservatively
E. If there are no neurological signs at presenta-
tion, it is unlikely any will develop as the
spine will be osteoporotic
58. A 27-year-old patient with a fracture dislocation
of C5/6 is admitted to your ward.
Which of the following best describes the
medical management required for this
patient?
A. At all times the mean arterial pressure should
be kept above 90mmHg and a systolic pressure above 100mmHg
B. Autonomic dysreflexia is a relatively uncom-
mon but life-threatening condition in peop le
who have a spinal cord injury above the level
of T6
C. Does not require pain relief for musculoskel-
etal spasms beneath the spinal cord injury
level
D. If described as having an ASIA impairment
scale (AIS) of ‘C’, their function is being
described as sensory incomplete
E. Should commence chemical thromboprophy-
laxis with low molecular weight heparin
within 10 days of admission
Tumour
59. A 45-year-old otherwise well female is referred to
you following assessment by a gynaecology colleague for pelvic pain, having been found to have
a lesion in the midline of the sacrum. Staging
identified this to be an isolated lesion. The cells
appear vacuolated on biopsy.
239
Paul Rushton and Niall Eames
What is the best description for the type of cell
the lesion derives from?
A. Endoderm
B. Mesoderm
C. Neuroectoderm
D. Notochord
E. Yolk sac
60. A 65-year-old male presents with an 8-week
history of back pain. He has no leg weakness or bladder/bowel symptoms. A full
neurological examination is normal. An
MRI scan of the whole spine is undertaken and
shown in Figure 11.20 with axial through the L3
level.
The next most appropriate action is which of
the following?
A. Biopsy
B. CT scan chest, abdomen and pelvis
C. Reassurance; the underlying pathology is a
benign haemangioma
D. Urgent decompression and stabilisation
E. Vertebroplasty
61. A 70-year-old man presents with progressive
weakness in both legs over 48 hours. He is now
struggling to walk but has minimal back pain and
remains continent. Usually he lives with his wife
independently, walking with a stick. On examination, power is 4/5 in lower limb myotomes with a
sensory level at T11. MRI images are shown in
Figure 11.21 with axial at T11. A staging CT is
suggestive of prostate cancer with metastatic
spread to the spine, right ilium and liver.
The most appropriate next step management of
this man is which of the following?
A. Biopsy
B. Decompressive laminectomy
C. Decompression and stabilisation
D. En bloc excision with reconstruction
E. Palliative radiotherapy, based on his
Tokuhashi score
Figure 11.20 (a) T1 and (b) T2 sagittal whole MRI spine images and (c) T2 axial cut at area of interest
240
Spine I Structured SBA
Figure 11.21 (a) T1 and (b) T2 sagittal whole spine MRI images and (c) T2 axial at T11
62. A 14-year-old boy presents with 3 months of
severe low back pain. The pain is worse at night
and relieved by ibuprofen. X-rays demonstrate a
small lumbar scoliosis.
Which of the following is true regarding the
likely underlying diagnosis?
A. It tends to affect the vertebral body
B. Radiofrequency ablation is the treatment of
choice
in the body of T5 with high signal on T1- and
T2-weighted imaging.
The most appropriate action at this point is
which of the following?
A. Biopsy
B. En bloc resection and reconstruction
C. Observation
D. Tumour decompression and stabilisation
E. Vertebroplasty
C. Recurrence is common following intrale-
sional curettage
D. The pathological lesion tends to be placed on
the concavity of the scoliosis
E. The radiolucent area in the lesi on is >2cm
64. A 58-year-old male presents with 9 weeks of
severe thoracic back pain, worse at night, causing
him to pace up and down the ward to try and
gain some reli ef. He is neurologically intact. An
X-ray shows a lytic lesion at T8. MRI of the spine
63. A 54-year-old with a history of breast cancer is
seen in the spine clinic. Her oncologist arranged
a whole spine MRI scan after a few weeks of
intermittent low back pain and asks for your
opinion. The MRI demonstrates a round lesion
shows normal spinal alignment with preservation of vertebral height at all levels. The lesion
in the body of T8 is dark on T1 and bright on T2,
with encroachment on the spinal cord. Following
blood test results, a bone marrow biopsy is
241
Paul Rushton and Niall Eames
undertaken showing plasma cells. He has trialled
conventional analgesics.
The most appropriate treatment at this time is
which of the following?
A. Medical management
B. Percutaneous stabilisation
C. Spinal decompression and stabilisation
D. Vertebrectomy and anterior reconstruction
with posterior stabilisation
E. Vertebroplasty
65. A 10-year-old girl presents with a 6-week history
of back pain. There is no history of trauma and
she is denying systemic symptoms. Plain imaging
and an MRI scan are shown in Figure 11.22.A
biopsy is undertaken.
The best description of the likely histology is
which of the following?
A. Bilobed eosinophils
B. Monoclonal plasma cells
C. Multinucleated giant cells
D. Small round blue cells
E. Spindle cells embedded in osteoid
66. A 35-year-old is started on a monoclonal anti-
body medication for initial treatment of their
sacral giant cell tumour.
The mechanism of action of this medication is
best described as which of the following?
A. Binds PTHrP
B. Increases osteoprotegerin
C. Induces tumour apoptosis
D. Inhibits farnesyl pyrophosphate synthase
E. RANKL antagonist
67. You are the on-call spinal surgeon at a regional
centre and referred a 60-year-old woman with a
background of breast cancer at 22.00 from a local
district general hospital (DGH). Over the past 5
days, she has noted progressive difficulty walking
and feels both legs are weak, but she remains
continent. On examination, she has minimal
back pain, power 4/5 in all lower limb myotomes
and altered sensation below the umbilicus. The
hospital does not have access to an out-of-hours
MRI scanner.
The most appropriate treatment at this point
is which of the following?
A. Administer oral dexamethasone
B. CT scan whole spine at DGH with soft tissue
rendering
C. Suggest contacting the oncologists for preo-
perative radiotherapy
D. Transfer to regional centre for imaging and
surgery that night
E. Transfer to regional spinal surgical centre for
overnight MRI scan
68. A 58-year-old male with a history of metastatic
prostate cancer diagnosed 4 months ago presents
Figure 11.22 Plain imaging (a) lateral, (b) PA views and (c) sagittal T2 MRI image
242
Spine I Structured SBA
with severe back pain over the thoracolumbar
junction. Pain is worse on attempted mobilisation. He is wearing a TLSO brace, which he finds
helpful, but he struggles to get out of bed eve n
with it. He has no neurological deficit. The
oncologists plan to start new treatments soon.
A CT and MRI scan show mixed lytic/blastic
metastatic lesions to the ilium and ribs but also
to L1 with tumour infiltrating the body, both
pedicles and superior articular processes. The re
is 20° kyphosis across the thoracolumbar junction associated with loss of vert ebral body heigh t
of around 25% and there is expansion of the
posterior wall indenting the dura.
The appropriate action at this point is which of
the following?
A. Posterior decompression and stabilisation
B. Posterior stabilisation
C. Refer to oncologists for consideration for
radiotherapy
D. Staged anterior and posterior decompression
and stabilisation
E. Vertebroplasty
69. An oncologist asks you to see a 43-year-old male
with a history of previous right nephrectomy 4
years ago for renal cell carcinoma. He presents
with severe thoracic back pain without neurological deficit. MRI, CT and PET imaging suggest an isolated metastatic lesion within the body
of T10. The spine is well aligned and there is no
neural compression.
The most appropriate next action at this point
is which of the following?
A. Anterior en bloc excision with reconstruction
B. Biopsy
C. Embolisation
D. Posterior intralesional resection decompres-
sion and stabilisation
E. Radiotherapy
243
Соседние файлы в папке Библиотека им академика М.И. Перельмана