1. Regarding normal spinopelvic alignment, which of the following statements is correct?

2. An implant company are encouraging a surgeon to change to a new type of rod for their scoliosis corrections. They propose changing from the 5.5mm diameter titanium alloy (Ti) rods the surgeon currently uses to their new 5.5mm diameter cobalt-chrome (CoCr) rods.

Which of the following is true?

3. A surgeon is undertaking a scoliosis correction with an all pedicle screw construct. They are keen to increase the strength of the bone–screw interface.

The surgeon is best to use a pedicle screw with which of the following?

4. In the normal intervertebral disc, the tissue derived from the primitive notochord is made of which collagen type predominantly?

5. As part of a lumbar central decompression you are removing compressive soft tissue material from the interlaminar region.

This tissue is made predominantly of which of the following?

6. You see a 12-month-old boy presenting with a congenital thoracic scoliosis. On counselling the parents on the anticipated natural history of the scoliosis, you describe that different congenital abnormalities have a varied degree of likely progression.

Which of the patterns below is most likely to lead to a progressive deformity?

7. Congenital scoliosis and its associated visceral abnormalities are due to interruption in the differentiation of which embryonic tissue?

8. A 9-month-old boy has been referred to you by a paediatrician he saw about his plagiocephaly as the physician noted a scoliosis. He is otherwise well with normal milestones and no apparent pain. Neurological examination is unremarkable. A radiograph demonstrates normal segmentation and a left thoracic scoliosis with Cobb angle of 15°. The rib head is in phase 1 and rib vertebral angle difference (RVAD) 16°.

The most appropriate management at this stage would be which of the following?

9. You assess a 7-year-old boy presenting with a scoliosis. A whole spine radiograph is shown in Figure 8.1.

The underlying diagnosis related to a mutation in which gene?

Figure 8.1 PA whole spine standing radiograph

10. You are seeing an otherwise well, pre-menarchal 12-year-old girl referred in with a thoracic scoliosis. Examination is unremarkable aside from the left thoracic scoliosis with a small rib hump. She has a normal neurological examination. Whole spine x-rays confirm the scoliosis with apex at T8 with Cobb angle of 20° and normal segmentation.

The most appropriate next step in management is which of the following?

11. What is likely to happen regarding her potential curve progression?

12. You are counselling the patient and family about the condition. They would like to know the likely outcome if left untreated.

You explain that without treatment, compared to someone unaffected, she is more likely to experience which of the following?

13. The patient opts for surgical management by way of posterior instrumented correction and fusion. Bending films are obtained, demonstrating the main thoracic curve reduces to 40°. A left-sided proximal thoracic curve measures 15° and lumbar curve 20° on the left bending film.

Surgery should aim to correct and fuse which of the following?

14. You are seeing a 10-year-old boy referred to you for recurrent falls. He has a complex background first noted on prenatal screening and had cardiac surgery in the first few weeks of life. He sees a paediatric orthopaedic surgeon about his hips, but they do not think the falls are related. He denies any pain, but his mother says he has seemed quite clumsy over the past few months. He has a flattened facial profile and nose. He looks to have a straight spine on examination but will not allow detailed neurological examination today.

The most indicated action at this point is which of the following?

15. You are seeing a 15-year-old girl in clinic with a background of quadriplegic spastic cerebral palsy, GMFCS 5, referred from a community paediatrician. Carers report problems with seating and care due to her spinal shape alongside poor nutrition and recurrent chest infections. She is seated poorly with signs of costo-pelvic impingement but with some curve flexibility on elevation. A sitting radiograph is shown in Figure 8.3.

Figure 8.3 AP whole spine sitting radiograph

Which of the following is the most appropriate action to take at this time?

16. A 14-year-old girl presents with low back pain and symptoms affecting her right leg. A standing radiograph is shown in Figure 8.4.

Figure 8.4 Standing lateral lumbar spine radiograph

Her symptoms are most likely to include which of the following?

17. A 14-year-old boy who bowls for his county attends with low back pain for the past 3 months. X-rays demonstrate a grade 2 lytic spondylolisthesis.

A step is most likely to be felt between the spinous processes of which of the following?

18. A 16-year-old dancer returns to clinic suffering with low back pain and severe bilateral radicular leg pain. X-rays demonstrate no change to her known grade 2 lytic spondylolisthesis at the lumbosacral junction. She previously responded well to repeated bilateral nerve root and pars blocks and physiotherapy, but symptoms have returned. Pain limits her daily activities despite suitable oral analgesia. She is requesting a more permanent treatment.

The most indicated treatment is which of the following?

19. A 15-year-old, previously well boy presents with back pain and a temperature of 37.8°C. He has paraspinal muscle spasm on examination, but neurological examination is normal. His CRP is 83 and WCC 17. MRI scans with axial through the level of interest are shown in Figure 8.5.

Figure 8.5 (a) Sagittal T2, (b) sagittal T1 with gadolinium enhancement and (c) axial T2 at level of interest MRI images lumbar spine

The most suitable next step in management is which of the following?

20. A 9-year-old boy presents with back pain and weight loss. He is ambulant and neurologically intact. Blood WCC is normal. A whole spine MRI shows enhancement of T10 and T11 vertebral bodies with preservation of adjacent disks with a small paraspinal abscess. On standing x-rays there is 15° kyphosis across the affected area with some collapse of the T10 and T11 vertebrae but is otherwise well aligned. A biopsy shows Langhans giant cells with cultures pending.

The most appropriate treatment at this time is which of the following?

21. A 60-year-old man has a fall from a standing height and is admitted via ambulance to A&E. He complains of cervicothoracic back pain. He is otherwise well aside from a history of ankylosing spondylitis. On examination, he is in discomfort but neurologically intact. Supine radiographs of the cervical, thoracic and lumbar spine are obtained that do not demonstrate a fracture.

The most appropriate action is which of the following?

22. A 65-year-old male presents with low back pain and pain radiating down the leg to the dorsum of the right foot.

From the list given, what is the most likely diagnosis?

23. A 67-year-old otherwise well male presents with pain down the medial aspect of both shins. MRI confirms that he has bilateral lateral recess stenosis in keeping with his presentation. His standing x-ray is shown in Figure 8.6. He has undergone appropriate conservative treatment involving a 6 weeks complete relief following bilateral nerve root blocks. His pain has returned, and he is requesting treatment.

Figure 8.6 Standing lateral lumbar spine radiograph

Which of the following is the most appropriate treatment?

24. A 65-year-old retired anatomist presents with radicular leg pain into the dorsum of his right foot. An MRI is undertaken showing lateral recess stenosis that accounts for his symptoms. You go on to describe the pathology.

In his case, the nerve root in question is most likely being compressed by which of the following?

25. A 67-year-old man presents suffering with left leg pain. He reports diffuse pain over much of the lower leg and foot without clear stenotic symptoms. He has no specific neurological deficit and good distal pulses. An MRI demonstrates multilevel pathology, including bilateral L4 foraminal stenosis, a grade 1 degenerative spondylolisthesis at L4/5 with associated lateral recess stenosis and broad-based left L5/S1 impinging on the traversing nerve root.

To guide targeted surgery, the most appropriate diagnostic injection is which of the following?

26. A 58-year-old female presents with back and bilateral leg pain. Her standing radiograph is shown in Figure 8.7. On recent MRI scan, central stenosis and lateral recess are contributing to nerve root compression, right-sided L4/5 facet joint cyst is present and the joints are aligned in the sagittal plane.

Figure 8.7 Standing lateral lumbar spine radiograph

Following confirmatory diagnostic injections, the most appropriate treatment is most likely which of the following?

27. A 40-year-old man presents with right shoulder and neck pain. On examination, he has weakness on Jobe’s / empty can test. Following exclusion of shoulder pathology, MRI imaging of his neck is undertaken, demonstrating nerve root compression concordant with his examination findings.

The nerve in question leaves the spine between the pedicles of which of the following?

28. A 36-year-old labourer presents with numbness over the right little finger. On examination, he has a globally reduced range of motion of his cervical spine, isolated altered sensation over the volar aspect of his right little finger but no wasting or weakness.

Which investigation is the most appropriate?

29. A 56-year-old plasterer presents with a 3-month history of neck pain. He feels the pain in the midcervical region in the midline and it is worse after a long day’s work. He is otherwise well. He has a reduced range of cervical motion which causes him pain but has no upper or lower limb symptoms or signs. An MRI had been arranged by his GP and is shown in Figure 8.8.

Figure 8.8 (a) Sagittal T2 and (b) axial T2 at C5/6 MRI images of cervical spine

The most appropriate action at this point is which of the following?

30. A 65-year-old otherwise well Caucasian female presents with right brachialgia. On questioning, she has noticed increasing difficulty with her sewing and some unsteadiness on her feet. Examination findings include an inverted supinator reflex.

Which pathology underlying this presentation is most likely?

31. You are undertaking the approach for an anterior lumbar interbody fusion at L4/5. While mobilising the vessels, you encounter significant hemorrhage.

An injury to which vessel(s) has most likely occurred?

32. You are seeing a 35-year-old who has had left leg pain to the lateral aspect of his foot for the past 8 weeks. He has no weakness or bladder/bowel symptoms. A recent MRI is shown in Figure 8.9 with axial at the L5/S1 level.

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