4.3 of 26 Ratings
A 68-year-old male with a history of colon cancer presents with worsening thoracic back pain, incontinence, and lower extremity weakness and numbness. Figure A is an MRI of the thoracic spine. Figure B is the tissue biopsy of the lesion. Which of the following statement is true regarding her condition?
On physical exam he will likely have hyper-reflexic patellar tendon reflexes
Tumor cells localize to vertebral body via binding osteocalcin
Osteolytic lesions are due to local release of endothelin-1
Radiation should be performed followed immediately by surgical decompression
Embolization should be performed before surgical decompression
Select Answer to see Preferred Response
A 59-year-old female patient with a history of metastatic breast cancer presents with increasing lower back pain that has worsened over the last 2 months She denies any motor weakness in the lower extremities, numbness, tingling, or any bowel and bladder changes. Figure A shows the current radiographs of the lumbar spine. Figures B, C, and D are the MRI images of the lumbar spine. Figure E is a recent biopsy of one of the lesions seen on imaging. What would be the most appropriate treatment for the spinal lesions?
Laminectomy with posterior spinal fusion
External beam radiation
Anterior column reconstruction with posterior stabilization
What factor has been shown to improve outcomes in revision metastatic spine surgery?
Preoperative radiation therapy
Surgery at greater than 6 levels
Tobacco use by patient
Immediate soft tissue reconstruction
Utilization of posterior approach
A 48-year-old woman with a history of chronic low back pain, narcotic dependence for 2 years, and recent IV drug abuse presents to the emergency room with worsening low back pain. She denies fever and chills, pain in her neck, or pain in her lower extremities. Physical exam shows normal strength, a negative Hoffman sign, 2+ patellar reflexes, and flexion of the 1st toes with a Babinski exam. Laboratory studies show a WBC of 12,000, a CRP of 3 mg/L, and an ESR of 13 mm/h. Plain radiographs are obtained and depicted in Figures A and B. What is the most appropriate next step in management?
CT of the chest, abdomen, and pelvis
MRI of the cervical spine
Blood cultures and empiric IV antibiotics
NSAIDS and physical therapy with close follow-up with a spine surgeon in 2 weeks
Which of the following tumors are most likely to cause the condition seen in Figure A?
Breast, Renal, Osseous, Lung
Breast, Hepatic, Colon, Lung
Breast, Osseous, Renal, Hepatic
Breast, Renal, Prostate, Lung
Breast, Renal, Prostate, Colon
A 60-year-old female presents with a 2-month history of low back pain. Imaging is seen in Figures A and B. Which of the following is LEAST likely to be true?
This patient is positive for mutations in the BRCA1 gene
The patient is positive for mutations in the APC gene and has a positive guaiac-based fecal occult blood test (gFOBT)
The patient has a 30 pack year smoking history
The patient presents with an ataxic gait, limb weakness, and is found to have a mutations of the von Hippel–Lindau tumor suppressor (VHL) gene
The patient presents with confusion, generalized weakness, and total serum calcium level of 12.1 mmol/L
Which of the following metastatic tumours should be treated with embolisation prior to surgical management?
A 62-year-old male patient presents with severe lower back pain radiating to his right lower abdomen and right leg. He previously underwent a right nephrectomy for renal cell carcinoma. On physical exam, he has weakness with right knee extension which is affecting his ability to ambulate. An MRI is performed and is shown in Figures A and B. Staging studies determine this to be an isolated metastatic lesion. What is the next best step in this patient's treatment?
Embolization, surgical decompression and stabilization followed by radiation
Surgical decompression and stabilization followed by radiation
A 68-year-old male presents to the emergency room with neck pain and progressive weakness to the point that he is unable to walk. Prior to this event he was in good health and active. On physical exam he is an ASIA C. Radiographs, computed tomography, and an MRI are show in Figure A,B, and C respectively. A CT of the chest, abdomen, and pelvis shows a single resectable lesion in the rectum consistent with a primary malignancy. Sagittal images of the spine show a single metastatic lesion in the thoracic spine, but no signs of thoracic canal compromise. He has no other metastatic bone lesions. What is the best treatment for this patient?
Radiation followed by surgical decompression and fusion
A 50-year-old woman with a history of metastatic breast cancer reports progressive back pain and lower extremity weakness over the past 2 weeks. The weakness has progressed to a point where she can only ambulate short distances with a walker. A sagittal T2-weighted MRI scan is shown in Figure A, and a sagittal contrast-enhanced T1-weighted MRI scan is shown in Figure B. Her cancer is found to be positive for a chromosomal translocation and the oncology team expects her to respond well to targeted therapy with a life expectancy of more than 3 years. What would be the most appropriate definitive treatment for this patient?
Palliative chemotherapy and radiation
Targeted radiation therapy
Laminectomy alone with posterior instrumented fusion with immediate pre-operative and post-operative radiation therapy
Corpectomy and anterior column reconstruction, followed by posterior instrumented fusion
Kyphoplasty with TLSO bracing, followed by biopsy-targeted medical management
You are caring for a 63-year-old female with metastatic breast cancer to the lumbar spine. Her neurological examination shows significant weakness in leg function and she is having difficulty ambulating. Imaging shows significant neural element compression by the tumor and complete erosion of the L1 vertebrae. She has no other sites of metastatic disease and is otherwise healthy. What treatment option do you recommend to best maintain her function?
Complete neural element decompression
Complete neural element decompression with instrumentation to stabilize the spine
Complete neural element decompression, instrumentation, and postoperative chemotherapy
Complete neural element decompression, instrumentation, and postoperative radiotherapy
A 59-year-old female with a history of biopsy proven metastatic renal cell carcinoma presents with a thoracic spine lesion consistent with renal cell carcinoma. She has lower extremity weakness and sustained clonus bilaterally. What is the most appropriate management prior to surgery?
High dose IV methylprednisone
CT guided cryotherapy
A 47-year-old female, otherwise in good general condition, has intractable back pain from metastatic breast cancer isolated to her spine. She has failed progressive multi-agent chemotherapy and hormone therapy. Her exam is normal except for slight sensory dysesthesia, hyperreflexic patellar tendons, and mild gait instability which she reports has been worsening. Cervical, thoracic, and lumbar MRI show an isolated metastatic lesion involving the T9 vertebral body with moderate cord compression of the ventral spinal cord. At this stage what is the best treatment?
Change chemotherapy protocol to Cyclophosphamide, Hydroxydanurubicin, Oncovin, Prednisone
Posterior spinal decompression after vertebral body kyphoplasty
Thoracic corpectomy, instrumented spinal fusion, and postoperative radiotherapy
Palliative care unit
A 67-year-old retired male custodian complains of progressively worsening low back pain over the past 6 months. He has not seen a doctor in the past 15 years. He admits to a 40 pack year smoking history, fatigue, and an unintentional 15 pound weight loss over the past year. A radiograph of the pelvis is provided in Figure A. Which of the following would most likely confirm the diagnosis?
Urine immunoelectrophoresis (UPEP)
CBC and blood smear
A 59-year-old female presents with a metastatic spinal tumor and has a lytic lesion in the T12 vertebral body. The process of bone resorption in her lytic lesion is mediated by
Direct resorption of bone by tumor cells
Neoangiogenesis of the vertebral body
Macrophage-mediated bony destruction
Tumor induced activation of osteoclasts
Necrosis of the vertebral body