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Introduction
  • Epidemiology
    • 95% involve L4/5 or L5/S1 levels
      • L5/S1 most common level
    • peak incidence is 4th and 5th decades
    • only ~5% become symptomatic
    • 3:1 male:female ratio
  • Pathoanatomy
    • recurrent torsional strain leads to tears of outer annulus   which leads to herniation of nucleus pulposis
  • Prognosis
    • 90% of patients will have improvement of symptoms within 3 months with nonoperative care.
    • size of herniation decreases over time (reabsorbed) 
      • sequestered disc herniations show the greatest degree of spontaneous reabsorption
      • macrophage phagocytosis is mechanism of reabsorption
Anatomy
  • Complete intervertebral disc anatomy and biomechanics
  • Disc composition
    • annulus fibrosis
      • composed of type I collagenwater, and proteoglycans  
      • characterized by extensibility and tensile strength
        • high collagen / low proteoglycan ratio (low % dry weight of proteoglycans) 
    • nucleus pulposus
      • composed of type II collagenwater, and proteoglycans
      • characterized by compressibility
        • low collagen / high proteoglycan ratio (high % dry weight of proteoglycans) 
          • proteoglycans interact with water and resist compression
        •  a hydrated gel due to high polysacharide content and high water content (88%)
  • Nerve root anatomy
    • key difference between cervical and lumbar spine is 
      • pedicle/nerve root mismatch
        • cervical spine C6 nerve root travels under C5 pedicle (mismatch)
        • lumbar spine L5 nerve root travels under L5 pedicle (match)
        • extra C8 nerve root (no C8 pedicle) allows transition
      • horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
        • because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots
        • because of horizontal anatomy of cervical nerve root a central and foraminal disc will affect the same nerve root
Classification
  • Location Classification
    • central prolapse
      • often associated with back pain only
      • may present with cauda equina syndrome which is a surgical emergency
    • posterolateral (paracentral)  
      • most common (90-95%)
      • PLL is weakest here
      • affects the traversing/descending/lower nerve root   
        • at L4/5 affects L5 nerve root
    • foraminal (far lateral, extraforaminal)   post
      • less common (5-10%)
      • affects exiting/upper nerve root   
        • at L4/5 affects L4 nerve root
    • axillary
      • can affect both exiting and descending nerve roots
  • Anatomic classification
    • protrusion
      • eccentric bulging with an intact annulus
    • extrusion
      • disc material herniates through annulus but remains continuous with disc space
    • sequestered fragment (free)
      • disc material herniates through annulus and is no longer continuous with disc space
Presentation
  • Symptoms 
    • can present with symptoms of
      • axial back pain (low back pain)
        • this may be discogenic or mechanical in nature
      • radicular pain (buttock and leg pain)
        • often worse with sitting, improves with standing
        • symptoms worsened by coughing, valsalva, sneezing
      • cauda equina syndrome (present in 1-10%)
        • bilateral leg pain
        • LE weakness
        • saddle anesthesia
        • bowel/bladder symptoms
  • Physical exam  
    • see lower extremity neuro exam
    • motor exam
      • ankle dorsiflexion (L4 or L5)
        • test by having patient walk on heels
      • EHL weakness (L5) 
        • manual testing
      • hip abduction weakness (L5)
        • have patient lie on side on exam table and abduct leg against resistance
      • ankle plantar flexion (S1)
        • have patient do 10 single leg toes stands
    • provocative tests
      • straight leg raise
        • a tension sign for L5 and S1 nerve root
        • technique
          • can be done sitting or supine
          • reproduces pain and paresthesia in leg at 30-70 degrees hip flexion
        • sensitivity/specificity
          • most important and predictive physical finding for identifying who is a good candidate for surgery
      • contralateral SLR
        • crossed straight leg raise is less sensitive but more specific
      • Lesegue sign
        • SLR aggravated by forced ankle dorsiflexion
      • Bowstring sign
        • SLR aggravated by compression on popliteal fossa
      • Kernig test
        • pain reproduced with neck flexion, hip flexion, and leg extension
      • Naffziger test
        • pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins
      • Milgram test
        • pain reproduced with straight leg elevation for 30 seconds in the supine position
    • gait analysis
      • Trendelenburg gait
        • due to gluteus medius weakness which is innervated by L5
Imaging
  • Radiographs
    • may show
      • loss of lordosis (spasm)
      • loss of disc height
      • lumbar spondylosis (degenerative changes)
  • MRI without gadolinium
    • modality of choice for diagnosis of lumbar and cervical disc herniations
      • highly sensitive and specific
      • helpful for preoperative planning
      • useful to differentiate from synovial facet cysts
    • however high rate of abnormal findings on MRI in normal people
    • indications for obtaining an MRI
      • pain lasting > one month and not responding to nonoperative management or
      • red flags are present
        • infection (IV drug user, h/o of fever and chills)
        • tumor (h/o or cancer)
        • trauma (h/o car accident or fall)
        • cauda equina syndrome (bowel/bladder changes)
  • MRI with gadolinium
    • useful for revision surgery
    • allows to distinguish between post-surgical fibrosus (enhances with gadolinium) vs. recurrent herniated disc (does not enhance with gadolinium)
Treatment
  • Nonoperative
    • rest and physical therapy, and antiinflammatory medications  
      • indications
        • first line of treatment for most patients with disc herniation
          • 90% improve without surgery
      • technique
        • bedrest followed by progressive activity as tolerated
        • medications
          • NSAIDS
          • muscle relaxants (more effective than placebo but have side effects)
          • oral steroid taper
        • physical therapy
          • extension exercises extremely beneficial
          • traction
          • chiropractic manipulation
    • selective nerve root corticosteroid injections
      • indications
        • second line of treatment if therapy and medications fail
      • technique
        • epidural
        • selective nerve block
      • outcomes
        • leads to long lasting improvement in ~ 50% (compared to ~90% with surgery)
        • results best in patients with extruded discs as opposed to contained discs
  • Operative
    • laminotomy and discectomy (microdiscectomy) post
      • indications   
        • persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections) 
        • progressive and significant weakness
        • cauda equina syndrome
      • technique
        • can be done with small incision or through "tube" access
      • rehabilitation
        • patients may return to medium to high-intensity activity at 4 to 6 weeks 
      • outcomes
        • outcomes with surgery compared to nonoperative
          • improvement in pain and function greater with surgery  
        • positive predictors for good outcome with surgery
          • leg pain is chief complaint 
          • positive straight leg raise
          • weakness that correlates with nerve root impingement seen on MRI
          • married status
        • negative predictors for good outcome with surgery
          • worker's compensation  
            • WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment
    • far lateral microdiskectomy post
      • indications
        • for far-lateral disc herniations
      • technique
        • utilizes a paraspinal approach of Wiltse 
Complications of Surgery
  • Dural tear (1%)
    • if have tear at time of surgery then perform water-tight repair
  • Recurrent HNP
    • can treat nonoperatively initially
    • outcomes for revision discectomy have been shown to be as good as for primary discectomy
  • Discitis (1%)
  • Vascular catastrophe
    • caused by breaking through anterior annulus and injuring vena cava/aorta
 

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Questions (11)

(SBQ12.8) A 45-year-old patient complains of leg pain associated with the pathology seen in Figure A. The patient undergoes microdiskectomy. During surgery there is no evidence of instability. Ten months later he re-develops similar symptoms of leg pain. A repeat MRI is consistent with a recurrent lumbar disc herniation. Which of the following most accurately describes the outcomes of revision surgery in comparison to primary surgery? Review Topic

QID:3706
FIGURES:
1

Equal limb pain and equal functional outcomes

54%

(1297/2389)

2

Improved limb pain and improved functional outcomes

11%

(269/2389)

3

Worsened limb pain and worsened functional outcomes

16%

(388/2389)

4

Worsened limb pain but improved functional outcomes

2%

(37/2389)

5

Improved limb pain but worsened functional outcomes

16%

(384/2389)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The clinical presentation is consistent with a recurrent lumbar disc herniation. Revision lumbar discectomy has been shown to have outcomes (pain and function) equal to that of primary lumbar discectomy.

Recurrent lumbar disc herniation is a common complication of lumbar discectomy procedure. These entities may initially be treated with anti-inflammatories, physical therapy and rest. If those initial measures do not work, selective nerve root injections can be used (epidural/selective nerve blocks). If these measures fail, then revision lumbar discectomy is the best surgical option; if there is evidence of instability at the level in question, a fusion procedure would be indicated.

Stambough et al. review management of recurrent lumbar disk herniations. They note that the majority of these cases can be treated conservatively. In cases where surgery is indicated, revision lumbar discectomy is the procedure of choice.

Patel et al. retrospectively reviewed 30 patients who had undergone primary and revision lumbar spine discectomy. Outcomes assessed were Visual Analogue Scales for back and limb pain (VAB & VAL) and the Oswestry Disability Index (ODI). They found similar, statistically significant improvements in limb pain and ODI scores. They conclude that revision discectomy can achieve results as good as those after primary discectomy.

Figure A shows a sagittal T2 weighted MRI sequence of a disk herniation at the L4-L5 level.

Incorrect Answers
Answer 2, 3, 4, 5: Revision lumbar discectomy has been shown to have as good outcomes in terms of pain and function as primary lumbar discectomy.


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(OBQ12.102) In patients with a symptomatic lumbar disc herniation who have failed nonoperative management, which of the following patient characteristics are associated with improved treatment effects with surgery? Review Topic

QID:4462
1

Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35

7%

(221/3020)

2

Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35

20%

(601/3020)

3

Age > 41 years, divorced, presence of worker compensation claim

1%

(30/3020)

4

Age < 31 years, absence of joint problems, no workers compensation

37%

(1130/3020)

5

Age > 41 years, absence of joint problems, married status

34%

(1016/3020)

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PREFERRED RESPONSE 5

Age > 41 years, absence of joint problems, and married status are associated with improved treatment effects in patients having surgery for lumbar disc herniation.

Lumbar disc herniations are a common cause of low back and leg pain. In the vast majority (>90%) the symptoms improve with nonoperative treatment within 3 months. However, a subset of patients have persistent pain and require surgery. Variables have been associated with outcomes with surgical treatment. The most frequently described is that workers compensation patients have worse surgical outcomes.

Weinstein et al. in the SPORT study found that in a combined as-treated analysis at 4 years, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status.

Pearson et al. in the SPORT study found the following patient characteristics were associated with improved treatment effects with surgical intervention for lumbar disc herniation: age > 41 years, absence of joint problems, a high school education or less, no worker’s compensation, duration of symptoms for over 6 months, being married, worsening symptom trend at baseline, and Mental Component Score (MCS) of less than 35.

Nguyen et al. looked at a cohort of Worker's Compensation patients and their outcomes following lumbar fusion. They found lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a Workers Compensation setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.

Illustration A shows the two most common positions of a lumbar disc herniation (paracentral-blue and foraminal-red). Illustration B shows a paracentral disc herniation at L4/5 on an axial MRI and shows how it affects the descending (L5) nerve root. Illustration C shows a foraminal disc herniation at L4/5 on an axial MRI, and how it affects the exiting (L4) nerve root.

Incorrect Answers:
Answer 1: Worsening symptoms at baseline and Mental Component Score (MCS) < 35 are associated with improved treatment effects.
Answer 2: Duration of symptoms > 6 mos and Mental Component Score (MCS) < 35 are associated with improved treatment effects.
Answer 3: Married and absence of worker compensation claim are associated with improved treatment effects.
Answer 4: Age > 41 years are associated with improved treatment effects.

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Question COMMENTS (1)

(OBQ12.230) A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. Leg pain and paresthesias are localized to his buttock, lateral and posterior calf, and the dorsal aspect of his foot. On strength testing, he is graded a 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis. Sagittal and axial T2-weighted MRI images are shown in Figure A and B. Which of the following treatment modalities will allow the greatest improvement of physical functioning? Review Topic

QID:4590
FIGURES:
1

Observation alone

1%

(29/2119)

2

Physical therapy

2%

(48/2119)

3

Medical management with GABA analogs

1%

(23/2119)

4

Discectomy

83%

(1761/2119)

5

Disectomy and instrumented fusion

11%

(234/2119)

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PREFERRED RESPONSE 4

The clinical presentation is consistent for a lumbar disc herniation with symptoms of a combined L5 and S1 radiculopathy that has failed to improve with extensive nonoperative treatment. At this time a discectomy would lead to the greatest improvement in physical functioning.

Anderson et al. reviewed the adequacy of randomized controlled studies completed over 25 years (1983-2007) that attempted to compare discectomy with non-surgical treatment. Given the high crossover rates and heterogeneity of outcome measures, the authors are unable to make conclusions as to the benefit of one treatment modality over another.

Weinstein et al. reviewed greater than 1000 patients who had imaging confirmed lumbar disc herniations; treatment modalities were non operative or operative (discectomy). Significant improved in physical function, bodily pain and disability scales were seen at even 4 years postoperatively.

Figures A and B show the axial and sagittal sequences of a T2-weighted MRI of the lower lumbar spine. A large L5/S1 para-central disc herniation is seen that has migrated cephalad. Therefore, it is irritating both the exiting L5 nerve root and descending S1 nerve root.

Incorrect answers
Answers 1, 2, 3: Many (> 90%) disc herniations have a self-limited natural history; the symptoms may be alleviated by bedrest and activites as tolerated, administration of anti-inflammatories or GABA analogs and completion of physical therapy. For symptoms that persist greater than 6 weeks and are disabling, surgery is indicated. Recent data from the SPORT trial suggests that functional outcomes may be improved by completion of discectomy.
Answers 5: Completion of a discectomy and instrumented fusion is not indicated in this patient. Without evidence of degenerative changes in the lumbar spine or evidence of spondylolisthesis, a posterior spinal instrumented fusion is not warranted.


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(OBQ11.65) A 33-year-old woman reports pain down her right leg and numbness across the dorsum of her right foot which started 3 months ago during a bowel movement. Prior to this she had had 1 month of low back pain. She had a lumbar microdiscectomy at L4/5 3 years ago which was successful. On physical exam she has weakness to ankle dorsiflexion and great toe extension on the right. Her new radiograph and MRI images are shown in Figure A and B respectively. After a failure of nonoperative treatment, which of the following is the most appropriate surgical treatment? Review Topic

QID:3488
FIGURES:
1

L4/5 microdiskectomy through midline approach

73%

(1387/1900)

2

L4/5 microdiskectomy with far lateral Wiltse approach

7%

(128/1900)

3

L4/5 Decompression, TLIF, and instrumented fusion

6%

(107/1900)

4

L4/5 Decompression, PLIF, and instrumented fusion

12%

(237/1900)

5

L4/5 Anterior Lumbar Interbody Fusion

1%

(27/1900)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The clinical presentation is consistent with a recurrent lumbar disc herniation. If conservative measures fail, the most appropriate treatment is revision microdiskectomy.

Papadopoulos et al. looked at a total of 27 patients who had undergone revision discectomies for recurrent lumbar disc herniation. They found revision discectomy is as successful as primary discectomy for patient satisfaction and function.

Suk et al. studied conventional discectomy for treatment of recurrent lumbar disc herniation and found results to be comparable to discectomy for a primary herniation.

Incorrect Answers:
Answer 2: A L4/5 microdiskectomy with far lateral Wiltse approach is indicated in a far lateral or foraminal disc herniation. An example of a far lateral disc herniation is shown in Illustration A.
Answer 3,4,5: A fusion would not be indicated at this time, as there is no sign of instability or spondylolisthesis.

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(OBQ11.236) A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. On physical exam, he is unable to go from a sitting position to a standing position with a single leg on the left, whereas he has no difficulty on the right. His patellar reflex is absent on the left, and 2+ on the right. Which of the following clinical scenarios would best produce this pattern of symptoms? Review Topic

QID:3659
1

Left L2-3 foraminal herniated nucleus pulposis

8%

(201/2462)

2

Left L4-5 central herniated nucleus pulposis

3%

(81/2462)

3

Left L4-5 paracentral herniated nucleus pulposis

10%

(253/2462)

4

Left L4-5 foraminal herniated nucleus pulposis

77%

(1887/2462)

5

Left L5-S1 paracentral herniated nucleus pulposis

1%

(24/2462)

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PREFERRED RESPONSE 4

This clinical scenario describes a patient presenting with an L4 radiculopathy. This is supported by his decreased patellar reflex and quadriceps weakness. A L4-5 foraminal (far lateral) herniated nucleus pulposis would most likely cause symptoms in the L4 distribution as foraminal herniations most commonly affect the exiting upper nerve root at a given lumbar level.

Rainville et al performed a study to identify the most sensitive physical exam test to detect quadriceps weakness caused by either an L3 or L4 radiculopathy. They found in L3 and L4 radiculopathies, unilateral quadriceps weakness was detected by the single leg sit-to-stand test in 61%, by knee-flexed manual muscle testing in 42%, by step-up test in 27% and by knee-extended manual muscle testing in 9% of patients. They conclude in L3 and L4 radiculopathies, unilateral quadriceps weakness was best detected by a single leg sit-to-stand test.

Deyo et al review the history, presentation, physical exam findings, and conservative treatment aimed at lumbar disk herniations. They describe the treatment modalities recommended (NSAIDS and early progressive mobilization) and those which are not recommended (narcotics and muscle relaxants). Physical examination maneuvers aimed at ruling out a diagnosis of cauda equina syndrome are imperative to understand and document as cauda equina syndrome is a surgical emergency.

Illustration A shows the location of different types of disk herniations. The red circle shows the location of a foraminal (far lateral) disc herniation. The blue circle shows the location of a paracentral disc herniation. Illustration B shows a T2 axial image of a foraminal (far lateral) disc herniation. Illustration C shows a T2 axial image of a paracentral disc herniation. Illustration D describes the difference between the cervical spine and lumbar spine with respect to nerve root anatomy.

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(OBQ10.18) Following surgical treatment of a lumbar disc herniations with radiculopathy, patients with worker's compensation claims have which of the following when compared to patients who do not have worker's compensation claims at 5 years? Review Topic

QID:3106
1

Equivalent relief from symptoms and equivalent improvement in quality of life

2%

(37/1590)

2

Less relief from symptoms and less improvement in quality of life

70%

(1107/1590)

3

Improved relief from symptoms and greater improvement in quality of life

1%

(11/1590)

4

Significantly decreased return to work status

27%

(427/1590)

5

Significantly improved return to work status

0%

(5/1590)

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PREFERRED RESPONSE 2

Patients with worker's compensation claims have less relief from symptoms and less improvement in quality of life following surgical treatment of lumbar disc herniations. Despite this, they have near equivalent return to work status at 4 years.

Atlas et al. (2006) showed at 5-10 years, most patients, regardless of baseline workers' compensation status, were employed (78% for both groups). However, workers' compensation patients had worse symptoms, functional status, and satisfaction outcomes.

Atlas et al. (2000) found patients who had been receiving Workers' Compensation at baseline had significantly less relief from symptoms and less improvement in quality of life, however, they were only slightly less likely to be working at the time of the four-year follow-up.


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(OBQ09.206) A 40-year-old female presents with right leg pain localized to the buttock, posterior thigh, and lateral calf. In addition, she describes numbness and tingling on the dorsum of the right foot. Physical exam shows weakness to EHL. Three months of nonoperative treatment including anti-inflammatory medication, physical therapy, and selective nerve root corticosteroid injections failed to provide lasting relief and pain is still severe in nature. Her MRI is shown in Figures A and B. What would be the most appropriate management at this juncture? Review Topic

QID:3019
FIGURES:
1

Refer the patient to pain management

1%

(9/1628)

2

Repeat epidural steroid injection

1%

(11/1628)

3

Transforaminal diskectomy

5%

(80/1628)

4

Laminotomy and diskectomy

90%

(1472/1628)

5

Spinal fusion with interbody cage and posterior instrumentation

3%

(50/1628)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

The patients clinical presentation and imaging studies are consistent with a L5 radiculopathy caused by a right paracentral disc herniation at L4/5 which is compressing the L5 nerve root. Because she has failed nonoperative management a laminotomy and diskectomy would be the most appropriate treatment.

A L4/5 paracentral disc involves the L5 nerve root. The muscles innervated by L5 nerve root include EHL and tibialis anterior, and therefore these patients may present with a "foot drop". While EHL is usually innervated by L5 alone, tibialis anterior has variable innervation by L4 and L5.

Weinstein et al. (SPORT 2 year results) showed as-treated analysis (prospective nonrandomized), discectomy was favorable with quicker improvement in symptoms for patients with surgery. They warn that the SPORT intent-to-treat analysis (prospective randomized) showed no statistical difference between those who had diskectomy vs. those who did not, but this data was disrupted by a very high crossover rate, and therefore most consider the as-treated analysis as a more accurate representation of the true clinical effect of treatment.

Weinstein et al (SPORT 4 year results) showed in the as-treated analysis that patients treated surgically for intervertebral disc herniation showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 4 years compared to patients treated non-operatively. They found at four years there was no significant difference in work status between the surgical and nonsurgical group.

Weber et al. look at a cohort that was randomized into surgical and non-surgical treatment for lumbar disc herniations. They found the controlled trial showed a statistically significant better result in the surgically treated group at the one-year follow-up examination. After four years the operated patients still showed better results, but the difference was no longer statistically significant.

Illustration A shows the lower extremity dermatomes. Illustration B shows how a laminotomy is used to access the disc and how an paracentral disc will affect the descending nerve root. Illustration C shows the difference between a laminotomy, hemilaminectomy, and laminectomy.

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(OBQ09.235) A 45-year-old male comes into your clinic complaining of right leg radicular pain that extends to the dorsal aspect of his right foot. On physical exam he has slight decreased sensation on the top of his right foot as well as 3/5 strength in his right EHL. He has 5/5 strength in the all other muscle groups in his lower extremities and symmetric 1+ patellar and Achilles reflexes bilaterally. Which axial MRI would be consistent with the patients symptoms Review Topic

QID:3048
FIGURES:
1

Figure A

7%

(113/1704)

2

Figure B

11%

(194/1704)

3

Figure C

43%

(730/1704)

4

Figure D

13%

(224/1704)

5

Figure E

26%

(437/1704)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The patient presents with a right sided L5 radiculopathy. The only axial MRI image that would cause a right L5 radiculopathy is Figure E, a far lateral L5/S1 disc herniation.

Radiculopathy secondary to a herniated lumbar disc can affect either the traversing nerve root or the exiting nerve root. Paracentral disc herniations are most common, and they affect the traversing nerve root, i.e. an L5/S1 paracentral disc herniation will cause S1 symptoms. Occasionally disc herniations are far lateral. In these cases, the disc herniation affects the exiting nerve root, i.e. an L5/S1 far lateral disc herniation will cause L5 symptoms.

Tamir et al reported that far lateral disc herniations are more common at L3/4 than L4/5 or L5/S1. Additionally, L3/4 disc herniations are more likely to be in older patients, and neurologic deficits are common.

Rhee et al. published a review on the anatomy, pathophysiology and treatment options for lumbar herniated discs.

Illustration A is a schematic showing how paracentral and far lateral disc herniations affect the traversing and exiting nerve roots respectively. Illustration B labels the anatomic structure in the axial MRI in Figure E.

Incorrect Answers:
Answer 1: This is a far lateral disc herniation at L4/5. This would present with right L4 symptoms
Answer 2: This is a facet cyst at L4/5. It would present with left L5 symptoms
Answer 3: This is a paracentral disc herniation at L3/4. This would present with right L4 symptoms
Answer 4: This is a paracentral disc herniation at L5/S1. This would present with right S1 symptoms

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(OBQ08.158) In patients with lumbar disc herniations resulting in significant unilateral leg pain but no functionally limiting weakness, surgical decompression has what long term effects when compared to nonoperative management? Review Topic

QID:544
1

Worse outcomes in pain, physical function, and return to work status at 4 years.

3%

(22/684)

2

Equivalent outcome in pain and physical function at 4 years.

46%

(314/684)

3

Improved outcome in pain and physical function at 4 years.

43%

(295/684)

4

Improved outcome in return to work status only at 4 years.

2%

(12/684)

5

Worse outcome in return to work status with equivalence in pain and physical function at 4 years.

6%

(38/684)

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PREFERRED RESPONSE 3

Recent evidence now supports that patients who undergo surgery for lumbar disc herniation have improved outcomes in bodily pain and physical function at 4 years.

Weinstein et al showed in the as-treated analysis that patients treated surgically for intervertebral disc herniation showed significantly greater improvement in pain, function, satisfaction, and self-rated progress over 4 years compared to patients treated non-operatively. They found at four years there was no significant difference in work status between the surgical and nonsurgical group.

Incorrect Answers:
Answer 1,2 &5: Surgical patients have improved outcomes in pain, physical function, at 4 years.
Answer 4: There is no difference in work status at 4 years.


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(OBQ08.240) A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding. Review Topic

QID:626
1

Weakness to hip flexion, numbness on the inner thigh, a decreased patellar reflex

4%

(26/658)

2

Weakness to knee extension, numbness on the anterior shin, a decreased patellar reflex

72%

(474/658)

3

Weakness to ankle dorsal flexion, numbness on the dorsal foot, a decreased Achilles reflex

17%

(112/658)

4

Weakness to extensor hallicus longus, numbness in the first web space, a decreased Achilles reflex

4%

(27/658)

5

Weakness to ankle plantar flexion, numbness on the lateral foot, normal reflexes

2%

(12/658)

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PREFERRED RESPONSE 2

This is a basic anatomy question. A far lateral disc herniation affects the exiting nerve root. At the L4/5 level this would be the L4 nerve root. The L4 nerve root innervates knee extension, the patellar reflex, and a sensory distribution that travels over the knee into the anterior shin. (see illustration A). Illustration B demonstrates the ASIA Classification of Spinal Injury diagram which also depicts ankle dorsiflexion as a test for L4.

ILLUSTRATIONS:

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(OBQ06.43) 45-year-old manual laborer presents to the office with acute onset back pain that radiates to his right leg after carrying a heavy object. He also has mild non-progressive weakness with ankle dorsiflexion on that side. A representative MRI cut is shown in Figure A. What should be his initial treatment? Review Topic

QID:154
FIGURES:
1

Microdiskectomy

6%

(102/1756)

2

Posterior spinal fusion with instrumentation

0%

(8/1756)

3

Decompression only

2%

(34/1756)

4

Strict bedrest

1%

(13/1756)

5

Anti-inflammatory medication and physical therapy

90%

(1587/1756)

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PREFERRED RESPONSE 5

Lumbar disc herniation is the most common cause of radicular pain in the adult working population. 95% of these herniations involve L4/5, L5/S1 lumbar disc spaces. Patients typically present with low back pain and sharp stabbing leg pain with sensory symptoms in a specific dermatomal distribution. Persistent intractable pain following non-surgical treatment during a minimum 6 week period is the most frequent indication for surgery.

The Weber article was a RCT over 10 yrs of 126 pt with sciatica due to herniated lumbar discs. The results of surgical treatment were significantly better than the results in the conservatively treated group after one year of observation, however this difference became much less pronounced after nine more years.

Saal et al retrospectively reviewed 11 patients treated nonoperatively with lumbar disc extrusions through CT/MRI to evaluate disc morphology initially and at follow up (mean 25 mos). Only 1 patient had progression of stenosis, and all patients had disc dessication at the level of disc herniation with contiguous levels being normally hydrated. All patients had a decrease in neural impingement.


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