In this patient, which symptom is least likely to be present:

Back pain Chronic spinal instability Correct, This patient shows ossification of the anterior and posterior

longitudinal ligaments. This would be seen in a patient who had ankylosing spondylitis and therefore would have back pain, peripheral joint pain, may have iritis and would certainly have stiffness of the spine. He is most unlikely to have chronic spinal instability.

Peripheral joint pain Iritis Stiffness of the spine

The AP view of this lumbo-sacral spine is:

Normal Shows a spondylo-listhesis Shows a spina bifida occulta Shows a lumbarised first sacral segment Correct, This patient shows a transitional vertebrae at

the lower lumbar spine. The transition in this x-ray is that S1 has become a lumbar vertebrae by virtue of the fact there is a disc space between what would now be termed L6 and S1. This is not an uncommon radiological finding and it is associated with an increased incidence of low back problems.

Shows a sacralised fifth lumbar segment

This woman has a fixed Thoracic Kyphosis measuring 60 degrees. Which one of the following would you NOT consider in your differential diagnosis?

Ankylosing Spondylitis Spondylolisthesis Correct, Sponylolisthesis does not result in a fixed kyphosis. Hemivertebra Unsegmented bar Scheuermann's disease

This x-ray:

Is a computerised axial tomogram of the foramen magnum Shows central displacement of the odontoid peg Correct, This computerised tomogram shows a

section through the atlas. The shape of the vertebra is typical and you can see the small lateral foraminae for the vertebral vessels. The opacity in the middle of the cord is that of the odontoid process and is abnormal in its position. This is in fact a central dislocation of the odontoid caused by rheumatoid. There is an obvious major risk of cord damage in this patient. An os odontoideum occurs when the tip of the odontoid process fails to fuse with the rest of the axis. In children it can be mistaken for a fracture of the odontoid process. However, the position of such an anomaly is normal. Therefore it should be within 2 mm of the anterior border of the atlas. It is never displaced centrally.

Is a normal appearance of the atlas Is a normal appearance of the axis Shows an undisplaced os odontoideum

This man has non mechanical back pain. The most likely diagnosis is:

Spinal infection Pagets disease Spinal neoplasm Sacro-ileitis Correct, The only obvious change on this radiograph is the obliteration of the sacro-

iliac joints. Both non specific sacro-ileitis and ankylosing spondylitis are causes of non mechanical back pain, the former occurring more commonly in women and the latter in men. All the pedicles and vertebral bodies as well as the body of the sacrum are intact and therefore there is no evidence of either tumour or infection. Fibrositis is a meaningless term and has no specific radiological features.

Fibrositis

An x-ray of this patient's lumbar spine would most likely demonstrate:

A scoliosis A Spondylolisthesis Correct, The exaggerated lumbar lordosis seen here is a typical example of

the deformity which is associated with a severe spondylolisthesis. You can also see the step that occurs in the lower lumbar spine due to forward slipping of one vertebra on the one below. Other associated features with this degree of listhesis would be the so called heart shaped buttocks, abdominal crease, tight hamstrings and a waddling type gait.

No abnormality Sacral agenesis A retrolisthesis

This patient presents with mechanical back pain. The x-ray demonstrates:

A retrolisthesis of L5 on S1 A spondylolysis of L5 Correct, This patient has a spondylolysis of the pars interarticularis

between L5 and S1. There is no displacement of the vertebral body and therefore there is no spondylolisthesis. There is a suggestion of a posterior displacement of the vertebral body of L4 and therefore this could be a retrolisthesis of L4 and L5. Scheuermann's disease is a fragmentation of the vertebral end plates and is not shown here. A spina bifida occulta shows up by defect in the lamina. The lamina is not seen in the lateral projection.

A scoliosis Scheuermann's disease A spina bifida occulta

Which one of the following is correct regarding this patient?

She must have a mobile scoliosis She can expect her spinal deformity to remain corrected when she is instructed to discontinue wearing

the brace She can expect relapse towards the original deformity after discontinuation of the brace.Correct,

This girl is being treated for her scoliosis with a Milwaukee brace. The object of this brace is to prevent the deterioration of the scoliosis. It does not correct the scoliosis in its own right. It is applied early in the development of the deformity and in successful cases is kept on until skeletal maturity when progress of the deformity is going to be arrested. On removal of the brace, there is a tendency to go back to the level of deformity the patient had initially. The scoliosis does not have to be mobile although the results are better if it is. It is most effective with the smaller degrees of deformity and large curves are often impossible to hold with this brace. The normal routine is to wear it all the time, taking it off only for relatively short periods.

Her spinal deformity must be greater than 50 degrees scoliosis to warrant its use The normal routine of use is to wear it by day and leave it off by night

This man

Is normal Has a hyperlordosis Correct, This man shows an exaggerated lumbar lordosis and a small

kyphosis. The whole spinal configuration is secondary to the large abdomen which is pulling the spine forward. This is the XXXX pregnancy. The same spinal configuration occurs in women for other reasons.

Has a fixed flexion deformity of the hip Has achondroplasia Has gynaecomastia

These lumps are most likely associated with:

Ankylosing spondylitis Rheumatoid arthritis Correct, These lumps are most likely associated with rheumatoid arthritis.

These are typical rheumatoid nodules commonly seen over the subcutaneous borders of the ulnar and also often seen in the fingers and adjacent to the flexor tendons of patients with rheumatoid arthritis. These lumps are associated with sero positive rheumatoid arthritis and usually indciate a fairly active stage of the disease. Ankylosing spondylitis, psoriatic arthritis and Reiter's syndrome are all sero negative polyarthridities and are not associated with nodules. The only nodules that osteoarthritic patients develop are Heberden's nodes around the distal inter-phalangeal joints and these are simply osteophytes.

Psoriatic arthritis Reiter's syndrome Osteoarthritis

The abnormality at the L3/4 disc space is most likely to be:

Caused by acute infection Indicative of acute disc prolapse Secondary to acute trauma Indicative of chronic segmental instability Correct, This x-ray shows sclerosis at the end plates of

adjacent vertebra in the lower lumbar spine. It also shows new bone formation at the margins of the end plates or the attachment of the anterior longitudinal ligament. These radiological signs are said to be indicative of chronic spinal instability. Even though the end plates are sclerotic, they are not eroded and therefore acute infectional tuberculosis is excluded.

Tuberculous

The spinal deformity seen here is a:

Scoliosis Spondylolisthesis Correct, The deformity seen here is a spondylolisthesis. The term refers to a

forward slipping of one vertebra on the one below. In this case, L5 has slipped forward on S1. As part of this pathology you can also see the elongated pars interarticularis.

Diastematomyelia Retrolisthesis Spina bifida

This computerised axial tomogram is taken at the level of the first cervical vertebra.

It is normal It shows central migration of the odontoid Correct, The radio-dense, circular lesion in the central

canal of the axis is the odontoid peg, which is grossly displaced. The patient had rheumatoid arthritis and the very slow rate of migration was not associated with any neurological symptoms. Nevertheless there is an obvious risk of severe neurological damage.

It shows central calcification of the spinal cord typical of syringomyelia There is a contrast enhanced spinal cord tumour There is congenital absence of the odontoid

The trabecular architecture of this lumbar spine:

Is normal Shows evidence of secondary neoplasia Correct, There are multiple radio-dense lesions

throughout this spine, most evident in the veterbral bodies. There are also poorly defined radiolucent areas scattered among the dense lesions. Less than half of the trabecular architecture looks normal. Multiple, combined radiodense and radiolucent lesions are invariably secondary deposits, usually from either a prostatic or breast primary. None of the other alternatives produce radiodense areas. Hyperparathyroidism can cause cystic lesions.

Shows changes characteristic of post menopausal osteoporosis Shows evidence of hyper-parathyroidism Is typical of osteomalacia