Abstract
Spine questions can feature at any station for viva. They are frequently asked in adult pathology, but can pop up in basic science (structure of intervertebral disc), trauma (thoracolumbar fractures and their management) or paediatrics (adolescent scoliosis).
For many candidates learning spine for the exam is a daunting task. But with smart preparation, these questions are actually gifts. There is a set methodology to answer them. Also, spine is like maths – neurology and level of pathology should add up. Besides, indications for surgery are specific and usually encompass neurology or instability.
Introduction
Spine questions can feature at any station for viva. They are frequently asked in adult pathology, but can pop up in basic science (structure of intervertebral disc), trauma (thoracolumbar fractures and their management) or paediatrics (adolescent scoliosis).
For many candidates learning spine for the exam is a daunting task. But with smart preparation, these questions are actually gifts. There is a set methodology to answer them. Also, spine is like maths – neurology and level of pathology should add up. Besides, indications for surgery are specific and usually encompass neurology or instability.
Each question is to be answered in 5 minutes. This is not a lot of time. This needs a lot of planning and practice. It is not only the knowledge you know, but also a smart and tactful way of getting it across in a timely manner.
By this time, you will be well aware of the marking process: minimum 6 pass for each question. But being humans, due to occasional anxiety or bad luck, there will be some setbacks (marking 5). So, plan for 7 or 8 at most stations. Try to stay calm and be positive. And no matter how bad the previous question was, forget it and recompose for the next question. Candidates who failed the exam are usually surprised as to how agonisingly close they were to passing and wished they had got the bad table out of their mind.
The usual format for a viva would be that a candidate would be shown a radiological picture (X-ray/CT/MRI) or a clinical picture and asked to describe it. This is followed by questions taking you to management. In other words, the sequence will be description of the picture or X-ray, followed by history, examination, investigations and treatment.
Describing an X-ray
Describe what X-ray it is first
PA and lateral standing X-ray of lumbar/thoracic/cervical/full spine showing …
Mention immature skeleton if you see a physis.
Lateral X-ray
1. Normal curves – cervical and lumbar lordosis, thoracic kyphosis.
2. Abnormal curves – exaggerated thoracic kyphosis, loss of lumbar/cervical lordosis, cervical kyphosis.
3. Disc height maintained or lost at any level. Fuzzy end plates could be a sign of discitis.
4. Facet arthritis.
5. Primary canal stenosis as evident by short pedicles.
6. Fracture – compression, burst, stable or unstable fracture.
7. Sagittal balance of full spine weight-bearing lateral – normal, positive or negative.
8. Listhesis – is it isthmic (if lysis of pedicles seen) or degenerative (facet arthropathy)?
Meyerding grading.
Pelvic tilt, sacral slope and pelvic incidence.
AP view
1. Cancer – winking owl sign – destruction of pedicle due to cancer.
2. Degenerative – facet arthritis or scoliosis (curve can be in either direction).
3. Idiopathic scoliosis – usually right convex in the thoracic spine (away from the heart).
4. Prolapsed disc – list away from nerve compression.
5. Evaluate pedicles always on AP view. Absent pedicle may be seen in metastases, aneurysmal bone cyst, osteoblastoma, trauma or congenital absence of pedicle.
Detecting the correct level
1. Highest point on the iliac crest usually points to L4/5 on the lateral view.
2. Count from C2 downwards if you have a full spine X-ray.
3. The twelfth rib can be helpful.
If confusion still exists between sacralization of L5 and lumbarization of S1, then it would be safe to comment on pathology based on the last mobile level. This is the level that has no bony connection to the pelvis, such as the large transverse process articulating with the ilium. This is usually the level where disc degeneration occurs.
History and examination
Unlike clinical cases, the advantage in a viva is that you won’t be utilizing precious time in waiting for answers from a patient. By the time you have described the radiograph, you know what the clinical scenario is and so a focused history is not a difficult task.
Every clinical scenario has some important questions that need to be asked. Examples include:
Sciatica – it is necessary to know the exact location of the leg pain (dermatome) as this will clinch the nerve root on the history alone.
Night pain – cancer in elderly.
Back pain worse than leg pain or significant back pain could mean instability.
An immunocompromised patient such as IVDU or a diabetic gives a clue of infection.
Please read the spine clinical cases chapter in the Postgraduate Orthopaedics book for the relevant questions in history-taking and examination.
As for clinical examination, always divide into general and local/spine examination. So, points like EWS in sepsis or chest expansion in ankylosing spondylitis in the general examination will not be missed.
Specific points of importance in the clinical examination are:
1. PR and perianal sensations in cauda equina.
2. Reflexes is a must – this helps to decide if the lesion is in the brain or the cervical cord (brisk in all four limbs) or thoracic spine (brisk only in lower limbs). It differentiates upper motor neuron lesion from a lower motor neuron.
3. Pulsations in feet to differentiate vascular pathology.
4. Location of tenderness – lumbar facet, sacroiliac joint, hip (groin).
Relevant investigations and management are discussed in each scenario.
Contents
1. Infection.
2. Spine metastases.
3. Benign tumour.
4. Cervical spondylotic myelopathy.
5. Lumbar prolapse disc with cauda equina.
6. Spondylolisthesis.
7. Ankylosing spondylitis.
8. Idiopathic scoliosis.
9. Non-idiopathic scoliosis.
10. Cervical disc prolapse.
Structured oral examination question 1
Infection (discitis)
EXAMINER: You are on call and you are asked to see a 45-year-old diabetic patient on the medical wards with back pain. The medics are concerned as she has raised blood markers and they can’t find any septic focus from their end.
CANDIDATE: Diabetic patients are immunocompromised and are prone for sepsis. I would like to take a detailed history, first wanting to know details of her back pain.
1. What is the onset, duration and progress of her back pain? Any trauma?
2. What’s the exact location? Cervical/thoracic/lumbar.
3. Is she able to mobilize? (Non-ambulatory usually suggests sinister pathology or advanced disease or instability.)
EXAMINER: What next?
CANDIDATE: I need to know more from her history.
1. Fever.
2. Neurology including bowel and bladder involvement.
3. Other joints if painful? Other red flags?
4. More details of her diabetes, is it Type 1 or 2, how well has it been controlled, is she diet-controlled/oral medications or insulin?
5. Any other septic focus including chest, urine, abdomen? Any other significant past history including medications?
EXAMINER: She is a Type 2 diabetic now poorly controlled, on insulin. The medics have ruled out all other septic focus. Nothing else significant on history and she is bedridden. She is struggling to sit or stand. No history of trauma.
CANDIDATE: I will then do a general and spine examination. What’s her EWS?
EXAMINER: This patient has no fever but a low temperature of 35 degrees. She also appears to be confused. What are you concerned about?
CANDIDATE: Sepsis is my major concern in this patient. Sepsis is SIRS with documented infection. I need to rule out an orthopaedic cause, primarily discitis, as this patient is complaining of back pain.
EXAMINER: (interrupting): What is SIRS?
CANDIDATE: SIRS is systemic inflammatory response syndrome and characterized by two or more of the following:
Fever (> 38°C) or hypothermia (< 36°C).
Tachycardia (> 90).
Tachypnea (> 20).
WBC >12 or < 4.
Altered mental state.
Blood glucose > 6.6 in absence of diabetes.
This patient already has two criteria needed for SIRS, namely altered mental state and hypothermia. My concerns are that she may progress to septic shock.
EXAMINER: She also has low blood pressure and tachycardia.
CANDIDATE: I need to rule out the spine or any other joint as a septic focus. I will do a detailed spine examination looking for specific point tenderness and progress to neurological examination.
EXAMINER: She has significant tenderness in her lower lumbar spine. No sensory–motor deficit in any of her limbs. PR normal. What next?
EXAMINER: Does it matter?
CANDIDATE: Brisk reflexes could suggest upper motor neuron lesion. If only in lower limbs it will mean a lesion in the thoracic spine. If in all four limbs this suggests a lesion in the cervical spine or brain.
EXAMINER: Reflexes are normal.
CANDIDATE: I would then proceed to investigations. I will look at her bloods FBC, U/E, RFT, serum lactate. The trend is more important in WBS, ESR and CRP than actual values. Also, I will request for portable radiographs of her lumbar spine.
I will then follow the Sepsis 6 pathway. This includes:
High-flow oxygen.
Blood cultures.
IV antibiotics.
IV fluids.
Check haemoglobin and lactate levels.
Measure urine output.
If feasible, I will ask for an MRI of her lumbar spine which is the primary diagnostic modality for spine infections.
EXAMINER: Please read this X-ray (Figure 6.1a,b).
Figure 6.1a,b Anteroposterior(AP) and lateral views of the lumbar spine.
CANDIDATE: These are AP and lateral views of the lumbar spine showing destruction of the vertebral end plates at L4/5 on the lateral view. There is no evidence of vertebral collapse. There is slight reduction on disc height at L5/S1.
EXAMINER: These are her MRI scans (Figure 6.1c–g).
Figure 6.1c MRI lumbar spine (T1 sagittal).
CANDIDATE: This is an MRI scan showing a hypointense signal at L4/5 on sagittal T1 (Figure 6.1c) and hyperintense on sagittal T2 (Figure 6.1d). There is loss of end plate definition on both sides of the disc. There is hyperintense vertebral marrow signal of L4 and L5 on fat-saturated T2 WI or STIR (Figure 6.1e). These changes are classical of discitis. There is no evidence of canal compromise on axial cuts (Figure 6.1f and Figure 6.1g). Also, there is no evidence of any epidural, subdural or intradural abscess.
Figure 6.1d MRI lumbar spine (T2 sagittal).
Figure 6.1e MRI lumbar spine (STIR) image.
Figure 6.1f MRI lumbar spine axial cut.
Figure 6.1g MRI lumbar spine axial cut.
CANDIDATE: Although metastases can lead to hypointense T1 and hyperintense T2 vertebral lesions, the disc space is always spared in malignancy. Also, the posterior elements are commonly involved in metastases.
EXAMINER: What will you do next?
CANDIDATE: The management of this patient will need a multidisciplinary approach. Treatment at this point of time is essentially supportive with the Sepsis 6 pathway. Her diabetes needs to be under strict control. I will start her on early empirical antibiotics after discussion with a microbiologist and infectious disease specialist until the causative organism is isolated. Parenteral antibiotics for 6–8 weeks in addition to a spinal brace for 6–12 weeks. At this point, she will need escalation of care and I will speak to HDU regarding the same.
Ideally, a biopsy would be ideal to decide the antibiotic. This can be done CT-guided depending on how stable the patient is. Also, a blood culture may provide a clue on the causative organism that should be done when the patient spikes a temperature.
I will keep a watch on her for worsening neurology and any further deterioration of her vital signs.
EXAMINER: What is the role of surgery?
CANDIDATE:
1. Epidural abscess – if significant neurology or worsening neurology.
2. Abscess with poor vitals to reduce the infective load, if fit for surgery. Interventional radiology may play a role.
3. Open biopsy in some cases to find exact organism and check drug sensitivity (e.g. Mycobacterium tuberculosis). Rarely done as CT-guided biopsy has replaced it.
4. Instability – healed infection with instability. Controversial as implant/surgery can lead to flare up of infection.
EXAMINER: What’s the most common pathogen? What’s the mode of spread?
CANDIDATE: Like most orthopaedic infections, Staphylococcus is the most common organism. E. coli is common within Gram-negative bacilli.
Bacteraemia (haematogenous – arterial) from an extra spinal primary source is the most common route of infection. This could be pulmonary, cardiac, urogenital, gut, cutaneous or mucous. Vascularized subchondral bone seeding occurs primarily with secondary involvement of the disc space and adjacent vertebrae. In children, however, the disc space infection is primary owing to vascular channels across the growth plate.
Other modes of spread are haematogenous – venous (Batsons plexus), lymphatic (more common in tuberculosis), direct (e.g. decubitus ulcer) or along cerebrospinal fluid pathways.
EXAMINER: How do you monitor response to therapy?
CANDIDATE: Symptomatic improvement like generalized feeling of well-being, reduction of back pain, increased mobility. Blood parameters like ESR, CRP and WBC. Also, serial MRI can be helpful.
CANDIDATE: The hypointense marrow signal seems to be improving on the T1 image (Figure 6.1h). So is the hyperintense T2 (Figure 6.1i) signal, suggesting that she is responding to the treatment.
Figure 6.1h MRI lumbar spine.
Figure 6.1i MRI lumbar spine.
EXAMINER: Thank you.
Learning points
1. Answer in a logical sequence of history, examination (general and local spine), investigations and management. Requesting blood cultures if a patient is pyrexic helps to isolate and identify a pathogen.
2. An immunocompromised patient with either fever or joint/back pain = BONE/JOINT INFECTION.
3. Fever is variable and can be present in less than 50% of cases. Some patients may not have an inflammatory response and fever may be absent.
4. Indications of surgery in infective spine usually are:
4.1. Neurology – worsening or advanced.
4.2. Instability (read White and Punjabi definition for instability).
4.3. Biopsy – if no improvement with antibiotics to find the causative organism, drug sensitivity or alternative pathology such as tumour.
4.4. Abscess – if no improvement with antibiotics and worsening of systemic features or neurology due to compression of neural structures by the abscess.
5. The above scenario tests management of a septic patient as well as spinal infection.
6. Adult versus paediatric spinal infection differences: vascular channels across the growth plate in children leading to primary infection of the disc.
7. Similar infective scenarios could be vertebral osteomyelitis, epidural abscess, spinal cord abscess, septic facet joint arthritis or paraspinal abscess.
Structured oral examination question 2
Metastases
EXAMINER: You see a 68-year-old man in your clinic with progressive back pain that’s worse at night and significant weight loss. How would you approach this patient?
CANDIDATE: His age, nocturnal pain and weight loss is suggestive of a sinister pathology such as infection or cancer. I will take a detailed history and examine … [being interrupted]
EXAMINER: What else do you want to know with history?
CANDIDATE:
Onset, duration, progress and its location (any point tenderness).
Aggravating or relieving factors, any trauma, radiation.
Severity and associated radiculopathy.
2. Neurology including bowel/bladder or gait involvement.
3. Other joints if painful? Other red flags?
4. For infections – any immunocompromised state such as being on steroids, diabetes or IVDU. Any other septic focus including chest, urine, abdomen?
5. Any other significant past history including medications, radiation or previous cancer?
6. Symptoms of other systems such as cough, abdominal pain and prostate symptoms to suggest any primary? Habits like smoking … [being interrupted]
EXAMINER: He is a chronic smoker with chronic cough and no other significant past medical history. He does complain of gait disturbances, though. His back pain is throughout thoracic and lumbar spine that is 8/10 on the VAS scale. There is no history of trauma. Nothing else is relevant on history.
CANDIDATE: I will proceed towards general and spine examination … [being interrupted]
EXAMINER: Nothing specific on general examination. Spine examination reveals tenderness along the entire thoracic and lumbar spine. He has no neurology in upper limbs but grade 3 power in lower limbs. PR is normal. Sensations are grossly normal.
CANDIDATE: What are the reflexes like?
EXAMINER: Brisk only in the lower limbs with upgoing plantar.
CANDIDATE: I am concerned about compression of cord in the thoracic spine, possible neoplastic aetiology with chronic smoking history and significant weight loss. I will get urgent blood investigations and radiological investigations.
Blood
Infective – FBC, CRP, ESR.
Metabolic – Ca, PO4, Alk PO4.
Neoplastic – Se electrophoresis, Se PSA, CEA.
Radiological
X-rays – full spine and chest in clinic.
MRI full spine.
EXAMINER: These are his X-rays of lumbar spine (Figures 6.2a, 6.2b).
Figure 6.2a Anteroposterior (AP) radiograph of lumbar spine.
Figure 6.2b Lateral radiograph of lumbar spine.
CANDIDATE: AP (Figure 6.2a) and lateral view (Figure 6.2b) of the lumbar spine. There is normal lordosis on the lateral view, but I can see compression of T11 vertebrae. I will need to see full-spine X-rays considering the fact that he has UMN signs in the lower limbs.
EXAMINER: T11 is the only abnormality on X-rays. What next?
CANDIDATE: Disc height is fairly preserved (not infective). I am thinking more of metastases. Because this patient has neurology, I will get him admitted and get an urgent MRI within 24 hours. My aim will be to find out the primary as well. I will request urgent CT chest/abdomen/pelvis and bone scan to see for extra-spinal metastases/primary.
EXAMINER: This is his CT chest (Figure 6.2c).
Figure 6.2c CT of chest.
CANDIDATE: There is a lesion in the right side of his chest, suggesting a primary in the lung. I will now manage this according to NICE guidelines for metastatic cord compression 2014 [1]. I will need an MRI and treatment plan within 24 hours.
EXAMINER: Please comment on the MRI scan (Figure 6.2d).
Figure 6.2d MRI lumbar spine, T1-weighted images.
CANDIDATE: MRI T1-weighted images of lumbar spine (Figure 6.2d) showing loss of normal signal of the marrow with a replacement of hypointense signal with involvement of multiple vertebral bodies. The T2 (Figure 6.2e) shows variable signal from hypointense to hyperintense to normal bone marrow. The T11 vertebral body is the most involved with compression of the cord, which can explain the UMN signs in the lower limbs. However, I need to see axial cuts as well as full-spine MRI.
Figure 6.2e MRI lumbar spine, T2-weighted images.
EXAMINER: Cervical MRI is normal. This is the thoracic MRI (Figure 6.2f and Figure 6.2g).
Figure 6.2f MRI lumbar spine.
Figure 6.2g MRI lumbar spine.
CANDIDATE: Thoracic MRI sagittal images (Figure 6.2f and Figure 6.2g) show multiple-level marrow infiltration with the cancer. T11 seems to be the major level of cord compression, but I would like to see the axial cuts as well.
EXAMINER: Yes, T11 is the major level of compression. What next?
CANDIDATE: As previously mentioned, this needs to be managed according to NICE guidelines for metastatic cord compression 2014. I will involve the local MSCC coordinator who will aid in decision-making, investigations, treatment and rehabilitation.
EXAMINER: Any further investigations?
CANDIDATE: I need to grade and stage this tumour.
Staging is to see the extent of spread of the tumour. This involves local and systemic staging. Local staging is MRI scan. Systemic staging is done by bone scan, CT of chest/abdomen/pelvis, PET scan or full-body MRI and is done to detect the primary and seek distant metastases.
Grading, on the other hand, is histology and is done by biopsy. Grading is the extent of differentiation of the tumour – low-grade undifferentiated or high-grade undifferentiated. Following the general principles applicable to all musculoskeletal tumours this biopsy should be done within the unit that will treat the tumour and samples should also be sent for culture. Biopsy all infections and culture all tumours.
Care must be taken in some metastases such as renal metastases that are very vascular and may need preoperative embolization prior to biopsy. Biopsy is needed if the primary is unknown.
EXAMINER: How would you decide about subsequent treatment?
CANDIDATE: The scoring system proposed by Tokuhashi [2] is useful in establishing indications for treatment and subsequent surgical goal. A poorer prognosis is correlated with a lower score. Six parameters are given a score from 0 to 2. A score of less than 5 indicates a life expectancy under 1 year and a palliative approach is suggested. A score of over 9 indicates a longer life expectancy and suggests resection/excision to be considered.
EXAMINER: His general condition is good otherwise and spine is the only metastases. What next?
CANDIDATE: Treatment options include:
Surgical decompression and stabilization.
Radiotherapy.
Vertebroplasty/embolization.
A combination of the above.
Radiotherapy is mainly for palliative treatment and reduces bulk. Radiotherapy is more reserved for prostate, most breast and lymphoreticular tumours. Also, it can be given pre- and postoperatively. There should be an interval of 6 weeks between radiotherapy and surgery to avoid wound problems.
Vertebroplasty/kyphoplasty probably has no role in this case as the patient has neurology. Besides, it is done to stabilize the spine while minimizing soft-tissue trauma facilitating a faster postoperative recovery in patients with limited life expectancy.
Embolization will be decided depending on the vascularity of the metastases on angiography that is usually an issue in renal metastases.
Here, I am more inclined for surgical instrumented decompression ± fusion depending on his fitness for anaesthesia and major surgery. Decompression of compressed neural structures may lead to functional improvement even with prolonged paraplegia. Simple laminectomy to ‘decompress’ the tumour is rarely indicated. This is because the presence of the tumour most frequently found in the vertebral body is likely to lead to mechanical instability and thus kyphosis. Instrumented stabilization is frequently undertaken.
Surgical resection of the tumour is aimed at improving survival. Resection may be undertaken anteriorly or posteriorly or both, and depending on the size and location of the lesion. In general terms, if a curative resection is hoped for, or survival is likely to extend beyond 6 months, intervertebral bony fusion should be undertaken to avoid instrumentation failure. If life expectancy is short and a palliative procedure is being considered, fusion may not be required, and posterior surgery is more commonly undertaken.
EXAMINER: How do metastases spread to the spine?
CANDIDATE: The spinal column is the most common site of osseous metastases of which thoracic spine is the most common. Spread can occur via:
Direct extension – lung cancer extending into the chest wall into vertebral bodies and posterior elements.
Haematogenous – Batson’s plexus, which is a longitudinal plexus of valveless veins running parallel to the spinal column. Tumours in multiple sites can metastasize to the spinal column without liver or lung involvement, e.g. prostate cancer.
Lymphatic.
CSF pathways.
CANDIDATE: Vetebral bodies contain bone marrow that has fat. This fat shows as a bright signal on T1. In metastases, this fat is replaced by cancer cells, leading to a reduced signal.
EXAMINER: Thank you.
Learning points
1. In cancers, the first aim is to confirm the diagnosis, then extent of spread and finally management.
2. Ask relevant questions to examiners when taking a history or asking about the findings of examination. This is just like an everyday clinic scenario.
3. Unless you ask for a relevant investigation, the examiner may not even show you the X-ray or MRI images.
General condition (poor 0, moderate 1, good 2).
Number of extra-spinal metastases (three or more scores 0, one or two scores 1, zero scores 2).
Number of spinal bony metastases (three or more scores 0, two scores 1, one scores 2).
Number of metastases to major internal organs (not removable 0, removable 1, no mets 2).
Tissue of origin (lung/stomach 0, kidney/liver/uterus 1, other/breast/thyroid/prostate/rectum 2).
Spinal cord palsy (complete 0, incomplete 1, none 2).
Excisional surgery > 9.
Palliative treatment < 5.
5. Neurology generally points to surgery unless in a very unfit patient or a very radiosensitive tumour such as lymphoma/myeloma, where radiotherapy is recommended.
6. Myeloma – CRAB (HyperCalcaemia, Renal failure, Anaemia, Bone lesions).
7. Prognosis – median survival in patients with metastatic bone disease.
a. thyroid: 48 months.
b. prostate: 40 months.
c. breast: 24 months.
d. kidney: variable depending on medical condition but may be as short as 6 months.
e. lung: 6 months.
8. Types of metastases:
Blastic – bone production exceeds bone destruction.
– Prostate in adults.
– Medulloblastoma, neuroblastoma, Ewing’s in children.
Lytic – bone destruction exceeds bone production.
– Renal, lung, breast and thyroid.
9. Differential diagnosis.
Blastic – haemangioma, Paget’s disease, osteosarcoma, benign osteoporotic compression fractures, renal osteodystrophy.
Lytic – multiple myeloma, lymphoma, spondylodiscitis (destruction of disc space with abnormal signal on either side of disc space).
10. Factors to be considered in offering treatment.
Neurology.
Type of cancer – radio-resistant, -sensitive.
Systemic disease – limited or extensive.
References
Structured oral examination question 3
Benign lesion
EXAMINER: You see a 35-year-old fit and healthy man complaining of insidious onset LBP, more severe at night. There is no history of trauma and no red flags on history.
CANDIDATE: Is the pain localized to one specific point in his back? Any neurology?
EXAMINER: Pain is localized to the right side of his back, for 6 months now. No neurology with no bowel or bladder symptoms. Nothing else is significant on history.
CANDIDATE: Night pain is a concern for me. If there is no other relevant history, I would like to go ahead with a general and spine examination.
EXAMINER: Nothing remarkable on general examination. Spine examination shows right-sided point tenderness in the L45 region with normal neurology. Other joints and distal pulsations are normal.
CANDIDATE: I will then proceed for investigations.
Blood
Infective – FBC, CRP, ESR.
Metabolic – Ca, PO4, Alk PO4.
Neoplastic – Se electrophoresis, Se PSA, CEA.
Radiological
X-rays and MRI full spine.
EXAMINER: Why X-rays?
CANDIDATE: Night pain is a red flag. I need X-rays.
EXAMINER: X-ray of the full spine is normal. All blood investigations are within normal limits.
CANDIDATE: I will proceed for MRI.
EXAMINER: This is a midsagittal T2 image (Figure 6.3a). Please comment.
Figure 6.3a MRI lumbar spine T2 sagittal image.
CANDIDATE: T2 sagittal image (Figure 6.3a) showing hyperintense signal in the L5 body. I want to see T1, axial and parasagittal images, please.
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