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Paul Rushton and Niall Eames
SPINE I STRUCTURED SBA ANSWERS
Basic Science
1. Answer D. Patients’ lumbosacral lordosis is pro-
portional to their pelvic incidence (PI)
Spinopelvic alignment is a complex topic, but is
now entering the sphere of the FRCS exam.
Sagittal vertical axis (SVA) refers to a C7 plumb
line, which should pass through the S1 end plate,
usually its posterosuperior corner. PI is an angle
from the centre of the femoral head axis to the
midpoint of the sacral plate and a line perpendicular to the sacral plate. As it relates the bony sacrum
to the ilium through the almost immobile sacroiliac
joints, it is a fixed anatomical parameter and does
not change following skeletal maturity.
Mathematically, PI = SS + PT. Usually, a patient’s
lumbosacral lordosis is approximately equal to
their PI. Commonly, a loss of lumbar lordosis is
fundamental to clinical sagittal balance problems,
and osteotomies may be undertaken to restore a
patient’s sagittal balance to a value similar to the PI.
Roussouly P, Nnadi C. Sagittal plane deform-
ity: an overview of interpretation and management. Eur Spine J. 2010;19:1824–1836.
2. Answer B. Changing from the Ti to the CoCr rod
as suggested will roughly double the bending
rigidity
Bending rigidity is equal to the SMA of the structure multiplied by the Young’s modulus of the
material. SMA of a solid circular rod is proportional to the fourth power of the radius. Young’s
modulus describes the gradient of the elastic part
of the stress–strain curve. Ti has a Young’s modulus of approximately 100GPa in comparison to
around 200GPa for CoCr; changing from the
former to the latter will roughly double the bending rigidity. While small differences in diameter
have a relatively large effect on rigidity, a change
in radius of only 0.25mm is insufficient to double
the bending rigidity, increasing it by a factor of
1.4. Ti is more ‘notch sensitive’ than CoCr.
3. Answer E. Larger thread depth
While pertaining to the spine, this is a simple
question about screw pull-out strength.
Cannulation tends to increase core diameter, which
reduces thread depth. A narrower pitch would
increase pull-out strength. The key screw-based
factor is increased thread depth, so is the best
answer. Increased thread (outer) diameter may
increase thread diameter but depends on any
change to core diameter.
4. Answer B. II
The notochord gives rise to the nucleus pulposus
of the intervertebral disc. The predominant collagen is type II. Proteoglycans, water and
chondrocyte-like cells are also present.
5. Answer A. Elastin
The ligamentum flavum is removed as part of a
lumbar decompression. It is attached to the cranial
edge of the inferior vertebra and anteriorly midlamina of the superior vertebra. Its dry mass is
predominantly elastin.
Paediatric Spine
6. Answer C. Renal ultrasound
A whole spine MRI scan in this age group requires
a general anaesthetic. Whilst there is a clear association of congenital scoliosis with intraspinal
abnormalities (around 30%), in the absence of
neurological concerns and good motor development this can be safely deferred until he is older. A
CT scan necessitates significant radiation dose.
This imaging may be prompted if surgery is being
considered but is not necessary at this point. There
is nothing to suggest a review by a paediatrician is
necessary; his motor milestones are satisfactory.
Other mesodermal congenital abnormalities
should be actively sought including renal and cardiac systems. A renal ultrasound is indicated.
Bracing does not generally affect the natural history of congenital scoliosis so is not indicated.
7. Answer E. Unilateral bar
The anticipated progression of a congenital scoliosis is determined by the growth disparity on each
aspect of the spine. Congenital scoliosis is classified as failure of formation, e.g. hemivertebra,
failure of segmentation, e.g. bar or a mixed abnormality. McMaster and Ohtsuka (1982) described
the natural histo ry of these abnormalities, identifying that for each type of deformity the progression was greater in midthoracic abnormalities
than upper thoracic-cervical and thoracolumbar
worst of all. Pertinent to the question, the pattern
244
Spine I Structured SBA
with the greatest progression was a unilateral bar
with contralateral hemivertebrae, followed by a
unilateral bar, two hemivertebrae, single hemivertebra and block vertebra in that order. Fully segmented hemivertebrae have two additional growth
plates than the contralateral side so a greater progression is anticipated than a semi-segmented
hemivertebra with a single additional growth
plate. Unsegmented hemivertebrae and incarcerated hemivertebrae have non-additional growth
plates so are usually benign.
McMaster MJ, Ohtsuka K. The natural history
of congenital scoliosis: a study of two hundred and
fifty-one patients. J Bone Joint Surg Am.
1982;64:1128–1147.
8. Answer E. Observation
This presentation is of infantile idiopathic scoliosis. He has only a mild curve. The rib phase and
RVAD are reassuring that this may resolve. At this
point the child needs close clinical and radiographic follow up only, every 4–6 months. At age
9 months, an MRI scan would need to be given
under a general anaesthetic. In the absence of
clinical findings suggestive of intraspinal abnormality with a small, potentially resolving curve, it
is reasonable to hold off an MRI scan at this point.
Cast treatment may be necessary if the curve is
shown to progress. There is no role for growing
rod or fusion surgery at this time.
Mehta MH. The rib-vertebra angle in the early
diagnosis between resolving and progressive
infantile scoliosis. J Bone Joint Surg Br.
1972;54:230–243.
9. Answer E. NF1
The radiograph shows a short sharp upper thoracic curve with potential pencilling of ribs on the
right, characteristic of a dystrophic curve associated with neurofibromatosis type 1 (NF-1).
Vertebral scalloping and enlarged neuroforamina
may also be seen in this condition. Scoliosis in
NFM1 may also be ‘non-dystrophic’ and look and
behave more like a typical idiopathic curve. This
autosomal dominant condition is diagnosed clinically using a defined criterion and relates to a
mutation in the neurofibromin 1 gene on chromosome 17. The criteria include cutaneous manifestations such as neurofibromas, axillary freckling
and café au lait spots. The remaining answers
relate to other genetic conditions associated with
scoliosis: Duchenne muscular dystrophy (dystrophin), osteogenesis imperfecta (COL1), Marfan
syndrome (FBN1) and spondyloepiphyseal dysplasia (COL2).
10. Answer C. MRI scan of whole spine
Despite the normal neurological examination in
an otherwi se well child, the presence of a left
thoracic scoliosis in an adolescent necessitates
investigation of the neuroaxis with MRI scan.
The rate of neurological abnormality in left-sided
curves is high, reported in 20–50% of cases
including Chiari malformation, tethered cord,
syringomyelia and diastematomyelia.
Wu L, Qiu Y, Wang B, Zhu ZZ, Ma WW.
The left thoracic curve pattern: a strong predictor
for neural axis abnormalities in patients with
‘idiopathic’ scoliosis. Spine (Phila Pa 1976)
2010;35:182–185.
11. Answer C. Her curve is likely to progress slowly
during adult life
This is a clinical description of adolescent idiopathic scoliosis (AIS), the progression of which is
largely governed by growth. The main period of
curve progression is during the patient’ s premenarchal growth spurt, over which time curves
may progress rapidly. This patient is skeletally
mature, now 2 years post-menarchal and Risser
grade 5 on the radiograph. However, given the
curve is >50° it may well still progress into adult
life, but any progression over the next few years
will slow, around 1°/year. RVAD is a useful
measure in infantile idiopathic scoliosis, not AIS.
Weinstein SL. Idiopathic scoliosis: natural
history. Spine 1986;11:780–783.
12. Answer B. Have concerns about cosmesis
An understanding of the long-term outcome of
untreated AIS is fundamental to decision making
for patients. The few available studies of longterm follow up of untreated AIS indicate that in
general it is a relatively benign condition.
Specifically, patients have no greater issue with
childbirth, and similar life expectancy, rates of
depression and general function to those
unaffected. While those with untreated AIS are
more likely to report back pain than those
unaffected, the severity is generally mild-
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Paul Rushton and Niall Eames
moderate, occurring only occasionally, with most
patients requiring analgesia only rarely. Patients
consistently report increased cosmetic concerns.
13. Answer D. Main thoracic curve
Level selection in idiopathic scoliosis correction
is controversial, but in the broadest terms fusion
should include all structural curves, with the
expectation that any compensatory nonstructural curves will reduce spontaneously. The
Lenke classification is useful in guiding level
selection and defines that in the coronal plane a
structural curve is one that remains 25° on
bending X-rays. By that measure, only the main
thoracic curve in this case is struct ural and needs
treatment, a Lenke 1 curve.
Lenke LG et al. Adolescent idiopathic scoli-
osis: a new classification to determine extent of
spinal arthrodesis. J Bone Joint Surg Am.
2001;83:1169–1181.
14. Answer A. Cervical spine flexion/extension
views
The description is in keeping with Down’s syndrome, the spinal ramifications of which include
scoliosis but also atlantoaxial instability. The
resultant myelopathy can present in subtle ways,
including recurrent falls, altered gait and apparent
clumsiness, necessitating a high degree of suspicion. Flexion/extension views of the cervical spine
will identify instability, allowing diagnosis in the
clinic. Further cross-sectional imaging may be
undertaken before treatment following these
simple investigations. As myelopathy is typically
progressive, simpleobservation should be avoided.
15. Answer D. Paediatric gastroenterology review
Decision making in neuromuscular scoliosis is
challenging. Long-term data would suggest
curves >40° before age 15 years are likely to
continue to progress. Bracing is largely not helpful in neuromuscular scoliosis. Surgery is well
demonstrated to improve quality of life for
patients and carers, but risks are high, including
wound infections, pneumonia and death. While
surgery may be indicated in this case, it is
important that if surgery is to be undertaken
risks are minimised with appropriate medical
optimisation. Given her poor nutrition, a PEG
should be considered preoperatively; input from
a gastroenterologist should be sought. Over this
period, detailed discussions can be had with the
family and wider care team regarding the potential benefits and risks of surgery in her case.
Surgery, if undertaken, would likely entail posterior correction and fusion to the pelvis, given
the pelvic obliquity, with an anterior release only
if extremely stiff.
Saito N, Ebara S, Ohotsuka K, Kumeta H,
Takaoka K. Natural history of scoliosis in spastic
cerebral palsy. Lancet 1998;351:1687–1692.
16. Answer A. Radicular pain felt onto the dor-
somedial aspect of the foot
The X-ray shows a lytic spondylolisthesis at the
lumbosacral junction. This typically results in L5
nerve root compression in the foramen, rather than
compression in the lateral recess as seen in degenerative spondylolisthesis. The only answer describing L5 symptoms is B. Answers A and E report L4
symptoms and answers C and D, S1 symptoms.
17. Answer D. L4 and L5
Lytic spondylolisthesis is most common at the
L5/S1 level. The spinous process, lamina and
caudal aspect of the pars remain in place with
the body of L5 and more cranial spine moving
anteriorly. The step is therefore felt between the
L4 spinous process, which has moved anteriorly
with the L5 body, and the relatively normally
placed L5 spinous process (Figure 11.23).
18. Answer B. In situ instrumented fusion of L5/S1
with decompression L5 nerve roots in their
foramina
The patient is suffering from both back pain and
leg pain; hence, surgery must aim to stabilise the
spondylolisthesis and decompress the L5 nerve
roots, which are compressed in their foramina.
Option C is not unreasonable but is less likely to
address the leg pain. While a controversial topic
in respect to high grade (3–4) spondylolisthesis,
reduction is not necessary for a grade 2 spondylolisthesis and woul d increase the risks of L5
nerve root injury. Option D, Gaines procedure,
is an option for spondyloptosis.
19 Answer D. Blood cultures
The description is of discitis. In a child with
suspected sepsis, empirical treatment is
246
Spine I Structured SBA
Figure 11.23 There is a fracture in the
pars interarticularis. The posterior arch of
L5 remains attached to the sacrum with L5
body and more cranial spine
displaced anteriorly
necessary, in accordance with Surviving Sepsis
Campaign Guidelines. Blood cultures should be
taken, ideally before administration of antimicrobials. In an otherwise well child,
Staphylococcus aureus is the most likely organism. Biopsy can be undertaken if the child fails to
respond to empirical antibiotics. There is no
significant epidural abscess shown on the scan.
Bed rest and the use of orthoses are often helpful
in infection, but the application is not a priority
at this time.
20. Answer C. Nine months of antimicrobials
The history, biopsy and MRI imaging are suggestive of spinal tuberculosis. Medical management is the mainstay of treatment; 2 months of
isoniazid, rifampicin, ethambutol and pyrazinamide and a further 7 month s of isoniazid and
rifampicin. Indications for surgery include progressive neurology, drainage of large collections
to aid antimicrobial penetration and current or
expected deformity. The patient has no current
neurology or significant deformity. There is no
mention of ‘spine at risk’ radiological signs as
defined by Rajasekaran (2001): separation of
facet joints, retropulsion of vertebrae, translation
of vertebral column and the toppling anteriorly
of spine cranial to the infection.
Dunn RN, Ben Husien M. Spinal tubercu-
losis: review of current management. Bone Joint
J. 2018;100-B:425–431.
Rajasekaran S. The natural history of post-
tubercular kyphosis in children: radiological
signs which predict late increase in deformity. J
Bone Joint Surg Br. 2001;83:954–962.
21. Answer C. Observation clinical and radio-
graphic follow up in 6–12 months
The radiographs demonstrate Scheuermann’ s
kyphosis characterised by wedging of 3 consecutive vertebrae >5° and endplate changes. She
appears to be skeletally mature: Risser 4 in keeping with her age and menarchal status. A brace
can be useful in those that are skeletally immature and helpful for pain and potentially improve
spinal shape. Surgery may be indicated if she
suffers significant progression, develops significant cosmetic concerns or intractable pain. In
most centres surgery would entail posterior
instrumented correction with posterior column
osteotomies. However, at this time reassurance
and observation is all that is required.
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Paul Rushton and Niall Eames
22. Answer: A. Left Lateral (Right side up), 7th rib
The patient is described as having a typical curve
i.e. right thoracic. As the approach is to the convexity of the curve they should be positioned with
right side up; left lateral. Given the obliquity of the
ribs’ visualisation is typically optimal approaching
through the rib two levels above the area of interest; in this case T9, thus the 7th rib.
23. Answer D. Short segment posterior instru-
mented fusion/resection of abnormality
This is a case of progressive congenital kyphosis
due to a posteriorly sited hemivertebra. Bracing
will not alter the natural history of this abnormality. Given the proven progression it is likely
to progre ss further as the child grows which may
have neurological sequelae; further observation is
not appropriate and surgery is indicated. The
principle of treatment is to negate the growth
disparity by achieving a posterior fusion. The
role for resection of the congenital abnormality
can be debated. Growing rods would necessitate
treatment of a large section of normal spine, are
ill suited to the control of kyphotic deformities
and mandate recurrent operations thus are not
indicated.
there was significant crossover between surgery
and conservative. But when analysed ‘as treated’
surgery was superior at 4 years in respect to
function and pain. The vignette describes L4
radicular pain secondary to lateral recess stenosis, which would be at the L3/4 level. The standing film demonstrates no spondylolisthesis.
From the given information, there is no indication for fusion. Note that even in the presence of
a degenerative spondylolisthesis, the indication
for fusion is debatable.
Weinstein JN et al. Surgical versus nono-
perative treatment for lumbar spinal stenosis
four-year results of the Spine Patient Outcomes
Research Trial. Spine 2010;35:1329–1338.
27. Answer E. Superior articular process of L5
All the options given can contribute to lateral
recess stenosis. But E is the preferred answer, as
the traversing nerve is typically compressed most
significantly between the hypertrophic superior
articular process and the vertebral body/disc in
the entrance zone of the lateral recess. This contrasts with central canal stenosis where the inferior articular process and ligamentum flavum
contribute most significantly.
24. Answer D. Spinal precautions, CT scan
Fractures in ankylosing spondylitis are commonly poorly seen on plain X-ray. Moreover,
ankylosis of the spine leads to long lever arms
and a propensity for highly unstable fracture
patterns. A high index of suspicion is needed to
safely manage these cases with a low threshold
for cross-sectional imaging.
25. Answer D. L4/5 lateral recess stenosis
The symptoms are of an L5 radiculopathy. From
the available options, this could be caused by an
L4/5 posterolateral disc prolapse or L4/5 lateral
recess stenosis. In a 65-year-old, lateral recess
stenosis would be the more common of the two,
so is the preferred answer. L4/5 foraminal stenosis
or L4/5 foraminal disc prolapse would compress
the exiting L4 nerve root. Central canal stenosis
rarely causes well-defined radicular symptoms.
26. Answer B. L3/4 decompression
The SPORT studies are of value when considering treatment for spinal stenosis. In the RCT,
248
28. Answer D. Left L5 nerve root block +/– further
injections
This is a common clinical presentation with diffuse symptoms and widespread MRI findings.
Epidural injections can be of diagnostic benefit
in central stenosis, to ensure a spinal cause of
claudication, but this presentation is of radicular
leg pain. Medial branch blocks and discography
assess the relative influence of the facet joint and
disc on a patient’s back pain. The most appropriate diagnostic injection would be a nerve root
block with potentially further nerve root blocks
depending on clinical response.
29. Answer C. L4/5 instrumented fusion and
decompression central canal and L5 nerve roots
in lateral recesses
The patient is presenting with degenerative spondylolisthesis at L4/5. This is characteristically
associated with L5 nerve root compression in
the nerves’ lateral recesses and central canal stenosis; hence, decompression will need to address
these areas. The indications for fusion in
Spine I Structured SBA
degenerative spondylolisthesis are debatable.
Patient’s age and likely bone quality influence
decision making. Facet joint effusions and cyst
and sagittally oriented facets are often considered
relative indications for fusion to limit cyst recurrence and iatrogenic instability.
30. Answer C. C4 and C5
Jobe’s test is predominantly of the supraspinatus,
supplied by C5. The C5 nerve leaves between the
pedicles of C4 and C5 where it can be commonly
compressed by a pathology such as a posterolateral C4/5 disc prolapse.
31. Answer E. Neurophysiological studies
The differential is of a C8 nerve compression or a
peripheral nerve lesion. The absence of brachialgia, dermatomal and myotomal neurological findings suggests a peripheral nerve lesion. The
examination findings suggest ulna nerve compression in Guyon’s canal. Being purely sensory, this is
likely to be distal to the deep motor branch (zone
3). The commonest causes in this area are ulna
artery thrombosis and aneurysm. Nerve conduction studies are the most appropriate investigation
at this time. If these do show ulna nerve compression, further imaging could be arranged.
32. Answer E. Reassurance, analgesia and
mobilisation
The MRI shows multilevel degenerative changes,
the axial image demonstrates disc osteophyte
complexes compressing the exiting C6 nerve
roots. This man presents with axial pain, potentially discogenic in origin. He has no radicular
symptoms or signs nor myelopathic features;
hence, there is no indication for nerve root
blocks or surgery. The patient should be
reassured at this point that there is no sinister
cause for his pain, and symptomatic management is required. If initial management between
the patient and GP is unsuccessful, onward pain
referral may be necessary, but a trial of simple
measures is most appropriate at this point.
33. Answer C. Cervical disc/osteophyte complex
The presentation is one of cervical radiculomyelopathy. All the available options can result in
myelopathy. From the answers offered, discosteophyte complex is the most likely. OPLL is
a common cause in the Asian population, particularly males. AAI is seen predominately in
inflammatory arthritis. The patient is described
as otherwise well, and an initial presentation of
inflammatory arthritis with AAI is very rare.
Thoracic disc prolapse can result in lower limb
upper motor neuron signs but would not explain
her brachialgia or reduced hand function.
34. Answer A. Ilio-lumbar vein
The retroperitoneal approach to the lower
lumbar spine requires vessel mobilisation to
access the disc spaces. All the answers given
could lead to significant bleeding. When accessing the L5/S1 disc, the median sacral vessels must
be mobilised and/or ligated. To access the L4/5
disc, the iliac vessels are mobilised to the right;
the ascending ilio-lumbar vein may need ligation
to allow this.
35. Answer C. Continued conservative treatment
will likely result in similar resolution of leg
pain at 1 year as surgery
The MRI shows a left-sided posterolateral disc
prolapse at L5/S1 with resultant S1 nerve root
compression. While surgery is commonly undertaken if radicular leg pain secondary to disc prolapse fails to settle after 6–12 weeks, it is vital to
understand the natural history of this pathology.
In an important RCT, Peul et al. (2007) randomised patients who had severe sciatica for 6–12
weeks to microdiscectomy or conservative treatment. While there was some crossover from conservative to surgery over the course of follow up,
the results are of significance. Surgery led to a
more rapid reduction in leg pain. At 1 year, the
leg pain, back pain and Roland Disability
Questionnaire scores were similar. Measures of
the total disability during the year were also
similar between the groups. Post-operative recurrence of sciatica leading to revision surgery
within 1 year was 3%.
Peul WC et al.; Leiden – The Hague Spine
Intervention Prognostic Study Group. Surgery
versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245–2256.
36. Answer A. C1–C2 fusion
The history is one of myelopathy; given the history of rheumatoid arthritis, cervical instabilit y is
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Paul Rushton and Niall Eames
the most likely underlying diagnosis. Given the
reduced PADI (abnormal: <14mm), atlantoaxial
instability is present. The tip of the dens is below
the McRae line, and the Ranawat’s index (abnormal <13mm female, <15mm male) suggests
basilar invagination is not present. There is no
suggestion of subaxial instability. Given this, the
treatment of choice is C1–2 fusion.
37. Answer A. Carotid sheath and pretracheal
fascia
The anterior approach to the cervical spine
involved cutting or splitting the platysma muscle
to identify and split the deep investing layer of
cervical fascia and develop a plane between the
carotid sheath and pretracheal fascia. The prevertebral fascia is incised and longus colli
retracted to expose the spine.
38. Answer B. IV antibiotics
This man has discitis. He has grown a characteristic organism from his blood cultures, so antibiotics can be tailored according to these
sensitivities. A biopsy may be of use if he fails
to improve on appropriate IV antibiotics.
Stabilisation is useful in resistant infections or
the presence of instability. There is nothing to
suggest decompression is necessary.
39. Answer B. Enhancement in the vertebral body
with preservation of the adjacent discs and elevation of the anterior longitudinal ligament
The history is suggestive of spinal infection or
malignancy. The Mantoux test confirms tuberculosis exposure. Characteristically, in contrast to
pyogenic infection described in A, TB infection
starts in the vertebral body, with preservation of
the adjacent discs, C. While significant bone loss
and deformity can occur, as described in D he is
likely to have neurological findings in the presence
of myelomalacia. B is suggestive of spinal metastases. E suggests osteoid osteoma/osteoblastoma.
40. Answer B. A poor correlation exists between
clinical finding and MRI findings
Clinical finding and MRI appearances correlate
poorly. MRI is still the gold standard means of
making a diagnosis. A post void residual volume
of less than 200 ml has a negative predictive value
of 97% for CES. A PVR volume of 550ml is a
strongly predictive measure of CES, but the diagnosis requires confirmation rapidly with an
emergency MRI scan, and assuming the diagnosis is confirmed emergent surgery – this is a
time-dependent condition (Venkatesan et al.
2019). PR is a poor test of nerve function – it is
neither sensitive nor specific. However, PR
examination needs to be documented during a
patient’s assessment along with other neurological tests. It is correct however that the cauda
equina nerves do respond poorly to pressure as
shown by animal models and have a poorly
developed myelin sheath. Historically, 24h was
thought to be an important time for neurological
recovery, but the more we learn we see that CES
is a time-dependent condition. The timing varies
for different patients. Each patient needs to be
treated with rapid assessment, diagnosis and surgery. 24 hours may or may not be critical for an
individual patient.
Venkatesan M, Nasto L, Tsegaye M, Grevitt
M. Bladder scans and postvoid residual volume
measurement improve diagnostic accuracy of
cauda equina syndrome. Spine 2019;44:1303–1308.
41. Answer D. When operated on an anterior
approach or a costo-transversectomy is considered lower risk for neurological deterioration than laminectomy
Upper thoracic disc protrus ion is seen uncommonly, most occurring in the lower thoracic
spine and seen more commonly in
Scheuermann’s disease. The anterior spinal tracts
are usually affected as the compression is anterior resulting in motor and proprioceptive problems. Calcification occurs in up to 40% of cases
which is seen well on CT scan, making this a
useful pre-operative workup. They are solid
pieces of disc: hard to remove. Access to the disc
can be performed through an anterior transthoracic or various postero-lateral approaches often
involving costo-transversectomy. Laminectomy
is associated with high neurological complication
rates given cord retraction is likely required to
access the disc.
42. Answer E. The overall complication rate for
lumbar decompression is around 12%
Every patient must be fully consented regarding
the potential for complications following all
250
Spine I Structured SBA
surgeries. Paralysis is a devastating complication
that can occur following any spinal surgery.
Dysphagia after ACDF is commo n, as high as
80% in the days following surgery. Usually it
improves quickly and resolves, but patients need
to be warned of this (Okaro et al. 2021). The
incidence of dural tear following lumbar discectomy is approximately 1% (Weinstein et al. 2006).
Most are managed at the time of surgery with
either repair, glue or patch. Bed rest for 24–48
hours may be required with the majority resolving with no long-term problems. The risk of C5
palsy is 5% following posterior cervical surgery,
but the prognosis is good with most patients
recovering their shoulder function with time. It
is thought to be due to the anatomical course of
the nerve (Liu et al. 2021). The overall complication rate following lumbar decompression is
12% which also rises with age and comorbidities
(Li et al. 2008).
Li G et al. Effects of age and comorbidities on
complication rates and adverse outcomes after
lumbar laminectomy in elderly patients. Spine
(Phila Pa 1976) 2008;33:1250–1255.
Liu B et al. Analysis of risk factors for C5
nerve root paralysis after posterior cervical
decompression. BMC Musculoskelet Disord.
2021;22:614.
Nasser R et al. Complications in spine sur-
gery. J Neurosurg Spine 2010;13:144–157.
Okaro I et al. Risk factors for postoperative
dysphagia and dyspho nia following anterior cervical spine surgery: a comprehensive study utilizing the hospital for special surgery dysphagia
and dysphonia inventory (HSS-DDI). Spine J.
2021;21:1080–1088.
Weinstein JN et al. Surgical vs nonoperative
treatment for lumbar disk herniation: the Spine
Patient Outcomes Research Trial (SPORT) observational cohort. J Am Med Assoc. 2006;296:2451–2459.
43. Answer: D Open spinal decompression/drain-
age and sampling
The history is in keeping with spinal infection.
The MRI shows a large epidural collection. At
this time he remains pyrexial with little change in
inflammatory markers despite antibiotics. The
organism is yet to be defined. It is logical to drain
the epidural abscess to achieve source control
and aid identification of an organism. There is
no sign of instability to suggest instrumentation
is necess ary. An ECHO is warranted to assess for
a source of the infection such as endocarditis, but
treatment of infection is the main priority currently. Working closely with microbiology/infectious diseases is crucial in such cases, whose
decision making regarding antimicrobials would
be aided by a sample of the infection. Crosssectional imaging may be useful if his infection
fails to settle despite abscess drainage and appropriate antibiotics over the coming days.
Trauma
44. Answer A. Ipsilateral weakness with contralat-
eral loss of pain and temperature
D described a central cord; E, anterior; C, posterior; and E, Brown-Séquard syndrome. B
describes compl ete cord injury. Brown-Séquard
carries the best prognosis.
45. Answer A. AC5
His bulbocavernosus reflex is present, indicating
the patient is no longer in spinal shock and his
neurological injury can be classified. He has no
sacral sparing, indicating a complete cord injury
(ASIA A). The most caudal level with motor
power 3 and intact sensation is C5, indicating
the neurological level of injury.
American Spinal Injury Association.
International Standards for Neurological
Classification of Spinal Cord Injury; 2019.
46. Answer A. Avulsion fractures of occipital
condyles
Occipital condyle fractures extending into the
base of the skull tend to be stable in comparison
to avulsion fractures, which are more suggestive
of OCD. The Powers ratio, measured on the
lateral radiograph, suggests an anterior OCD
when the distance between the basion and posterior arch of C1 is greater than the distance
from the opisthion to the anterior arch of C1,
i.e. ratio >1.0. Harris’s rule of 12 states a BDI
and BAI <12mm to be within the normal range.
47. Answer E. Transverse ligament is NOT dis-
rupted and C1–C2 fusion is NOT indicated
The CT shows fractures of the anterior and posterior arch of C1 on the right side. The left arch is
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Paul Rushton and Niall Eames
incompletely seen on this axial cut; in any case,
the question details that the injury is right sided.
The coronal image demonstrates no significant
displacement and no overhang of the lateral
masses of C1 on C2. In other cases, a combined
overhang of >6.9mm (8mm on plain film
allowing for magnification) suggests the transverse ligament is disrupted and the fracture is
unstable, necessitating surgery by way of C1–2
arthrodesis or at least rigid external orthosis, e.g.
halo. The injury in this case, with seemingly
intact transverse ligament, is considered stable
and can be managed in a collar.
48. Answer D. Rigid cervical orthosis
This describes a type III fracture via the
Anderson and D’Alonzo classification, which
has a high rate of union and in the absence of
significant displacement can be managed nonoperatively. Alignment can be maintained while
union occurs with a cervical collar or halo jacket.
Anterior screw fixation is an option for type II
fractures. C1–C2 fusion is an option acutely in
grossly displaced type II fractures or in the setting of fracture non-union. Goel-Harms type
fixation involves stabilisation with rods and
screws gaining purchase with C1 lateral mass
screws and C2 pedicle screws.
49. Answer D. Non-union
Application of a halo vest in the elderly is associated with significant morbidity and mortality,
around 50% and 40%, respectively. However,
several studies suggest a higher union rat e with
halo vest vs semi-rigid collar. It can be argued
that a stable fibrous union is a satisfactory outcome in a frail elderly patient, with the chance of
late neurological deterioration with myelopathy
reportedly very small.
50. Answer D. MRI scan
This CT shows anterolisthesis of over 50% of C6
on C7 due to bifacetal dislocations, seen on the
parasagittal images. The patient has an incomplete cord injury and concomitant head injury.
This is a controversial topic, in particular the
need for an MRI scan before reduction, to identify a disc injury that may cause cord injury on
reduction. Cervical traction, without MRI scan,
is suitable management for a patient with a
neurological injury who is alert and able to
comply with serial examinations, to allow
removal of traction if a neurological deterioration occurs. In a patient who cannot comply
with serial examinations , e.g. intoxicated, intubated or head injury or the patient is neurologically intact, an MRI is indicated, prior to
reduction. The use of steroids in cord inju ry is
another controversial topic, with the NASCIS
trials open to interpretation. Most centres in the
UK, in keeping with the UK NICE guidelines, do
not use steroids in acute cord injury. The patient
requires reduction and stabilisation, not a halo
jacket.
51. Answer E. The patient can be consid ered to
have a ‘stable’ spine. All cervical protection
can be removed, and the patient positioned
carefully in theatre
Maintenance of spinal precautions can lead to
morbidity and practical issues in ITU. MRI scans
are also impractical. A fine-cut CT scan reported
by a senior radiologist is sufficient to clear the
spine, allowing removal of spinal protective
devices. Naturally, any trauma patient should be
carefully positioned intraoperatively. Isolated
lumbar spine transverse process fractures are of
no structural consequence. Log-rolling is to be
avoided, if at all possible, in the setting of an
unstable pelvic fracture.
British Orthopaedic Association Standard
for Trauma (BOAST). BOAST 2 Spinal
Clearance in the Trauma Patient; 2008.
52. Answer D. Osseoligamentous flexion distrac-
tion injury
The history, clinical findings and CT are in keeping with an AOSpine B2 injury (osseoligamentous flexion distraction injury). This involves loss
of the posterior tension band suggested by the
posterior tenderness and swelling, the distraction
between spinous processes of T12 and L1 as well
as potential avulsion fracture from the spinous
process of T12 on CT. While there is an associated body fracture (incomplete burst, AO A3),
the distraction element is the key aspect in
understanding the fracture pattern. Erect radiographs are important in fracture management,
with measurements made on supine imaging less
informative.
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Spine I Structured SBA
53. Answer E. Surgery; short segment fixation T12–
L2/L3 with fusion
This is an unstable pattern and surgery is indicated. Posterior ligamentous healing is unpredictable, so fusion is indicated across the
disrupted soft tissues, in this case, T12–L1.
There is a minor body fracture of L2 hence
instrumentation may need to extend to L3
depending on screw purchase. Long segment fixation or anterior + short segment posterior surgery is more often indicated in type C injuries
and those with significant vertebral body fragmentation and displacement.
The Thoracolumbar Injury Classification and
Severity Score (TLICS) can be applied, scoring 7
[Morphology = distraction (4), posterior ligamentous complex = disrupted (3), neurologically
= intact (0)] indicating surgery.
Vaccaro AR et al. A new classification of
thoracolumbar injuries: the importance of injury
morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine
2005;30:2325–2333.
Vaccaro AR et al.; AOSpine Spinal Cord
Injury & Trauma Knowledge Forum. AOSpine
thoracolumbar spine injury classification system:
fracture description, neurological status, and key
modifiers. Spine 2013;38:2028–2037.
54. Answer B. Burst fracture
The vertebral body fracture involves the posterior wall, indicating a burst pattern of the body,
which would be A4 by the AOSpine classification. There is no suggestion clinically or radiologically of injury to the posterior tension band,
which would indicate a flexion-distraction, AO B
type injury. There is no translation or rotation, C
type features.
55. Answer C. Mobilisation and standing radio-
graphs when pain allows
The description is of a burst fracture in good
alignment on supine imaging with a patient
showing some nerve root irritation but no other
neurological concerns. An MRI could be of use
to further image the posterior ligamentous complex but can be difficult to interpret in the
trauma setting. A trial of conservative management is appropriate with standing radiographs
once patient is able. A failure to mobilise in a few
days to get the radiographs or significant
kyphosis on standing would necessitate a reevaluation of diagnosis and treatment with consideration of surgery.
The Thoracolumbar Injury Classification and
Severity Score (TLICS) can be applied, scoring 4
[Morphology = burst (2), posterior ligamentous
complex = intact (0), neurologically = nerve root
(arguably scores 2)], suggesting conservative
management.
Jaffray DC, Eisenstein SM, Balain B, Trivedi
JM, Newton Ede M. Early mobilisation of thor-
acolumbar burst fractures without neurology: a
natural history observation. Bone Joint J.
2016;98-B:97–101.
Mehta JS, Reed MR, McVie JL, Sanderson
PL. Weight-bearing radiographs in thoracolum-
bar fractures: do they influence management?
Spine 2004;29:564–567.
56. Answer: D: Posterior instrumented fusion with
long construct
This patient has a grossly unstable T12/L1 C pattern spinal injury with associated spinal cord
injury and visceral injury. She is described as
haemodynamically stable and lab results confirm
this, thus further resus is not necessary. An MRI
scan may be indicated in due course but is not
likely to change the spinal surgical plan at this
time. Immediate spinal stabilisation will help limit
secondary cord injury, allow the general surgical
treatment to be carried out in a more stable environment and avoid stress on any surgical repairs
that prone positioning for spinal stabilisation
would necessitate. Methylprednisolone is not
indicated.
57. Answer 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
Although there are many similarities among AS
patients possessing HLA-B27 and those lacking
this gene, the former group has a younger age of
onset, a shorter delay in diagnosis and a better
clinical response to tumo ur necrosis factor
inhibitors (Akkoç et al. 2017). Any patient with
ankylosing spondylitis presenting following an
injury – no matter how minor, should be
assumed to have a fracture until proven
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