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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?
Equal limb pain and equal functional outcomes
Improved limb pain and improved functional outcomes
Worsened limb pain and worsened functional outcomes
Worsened limb pain but improved functional outcomes
Improved limb pain but worsened functional outcomes
Select Answer to see Preferred Response
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?
Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35
Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35
Age > 41 years, divorced, presence of worker compensation claim
Age < 31 years, absence of joint problems, no workers compensation
Age > 41 years, absence of joint problems, married status
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?
Medical management with GABA analogs
Disectomy and instrumented fusion
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?
L4/5 microdiskectomy through midline approach
L4/5 microdiskectomy with far lateral Wiltse approach
L4/5 Decompression, TLIF, and instrumented fusion
L4/5 Decompression, PLIF, and instrumented fusion
L4/5 Anterior Lumbar Interbody Fusion
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?
Left L2-3 foraminal herniated nucleus pulposis
Left L4-5 central herniated nucleus pulposis
Left L4-5 paracentral herniated nucleus pulposis
Left L4-5 foraminal herniated nucleus pulposis
Left L5-S1 paracentral herniated nucleus pulposis
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?
Equivalent relief from symptoms and equivalent improvement in quality of life
Less relief from symptoms and less improvement in quality of life
Improved relief from symptoms and greater improvement in quality of life
Significantly decreased return to work status
Significantly improved return to work status
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?
Refer the patient to pain management
Repeat epidural steroid injection
Laminotomy and diskectomy
Spinal fusion with interbody cage and posterior instrumentation
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
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?
Worse outcomes in pain, physical function, and return to work status at 4 years.
Equivalent outcome in pain and physical function at 4 years.
Improved outcome in pain and physical function at 4 years.
Improved outcome in return to work status only at 4 years.
Worse outcome in return to work status with equivalence in pain and physical function at 4 years.
A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding.
Weakness to hip flexion, numbness on the inner thigh, a decreased patellar reflex
Weakness to knee extension, numbness on the anterior shin, a decreased patellar reflex
Weakness to ankle dorsal flexion, numbness on the dorsal foot, a decreased Achilles reflex
Weakness to extensor hallicus longus, numbness in the first web space, a decreased Achilles reflex
Weakness to ankle plantar flexion, numbness on the lateral foot, normal reflexes
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?
Posterior spinal fusion with instrumentation
Anti-inflammatory medication and physical therapy
I created this video with the YouTube Video Edito
In this video Dr. Jeffrey P. Johnson explains how to identify a far lateral lumb...
This video demonstrates a case presentation of a microdiskectomy utilizing a par...
HPI - The patient is 59-year-old male that was moving a tree branch when he developed severe pain in his left leg 10 days ago. He localizes the pain to his knee and his medial calf and ankle. He reports his pain was so severe initially he could not get off the ground, and has remained severe enough that he is unable to perform ADL, and is having difficulty sleeping. He was given a steroid taper and narcotics by his PCP, but his symptoms remained severe so an MRI was performed and he was referred to my office. He does report initially he could not "extend his knee", but reports that is improving.
Would you operate on this patient acutely
HPI - The patient presents with 6 week hx of rt side leg pain and paraesthesia below knee in the S1 dermatome. He has a mild backache, no fever, no weakness. Pain intensity changes with position. It is mild in the morning and increases gradually. It is worse with sitting more than 30 minutes. Current management with NSAISs and physical therapy.
What would be your next step in management for this patient?
HPI - Patient is 32-year old orthopedic surgeon with history of right side S1 radiculopathy for 8 months that progressed to bilateral S1 radiclopathy for last 3 months. Epidural steroid injection after 1st 2 month did not lead to improvement in sign and symptom. No complaints of muscle weakness and no bladder or bowel involvement.
Paraesthesia improved after first 3 month. Pain last 2 month increase , interfere significantly with daily activity
Lumbar discectomy performed in 4 / 12 / 2013.
Fenestration done and sequestrectomy done .
Surgeon how did the surgery tell me he found all disc sequestrated annulus healed no any further compression on root .
Bleeding from epidural vein occur , gel foam
Postop. No any improvement ,still bilateral S1 radiculopathy more sever in right side with intermitten throbbing pain in right paraspinal area at level of sacral ala at rest With Backache
The pain even more intense than preoperative p
what your opnion about the case