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Average 3.8 of 64 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 45-year-old male underwent a lumbar discectomy 8 weeks ago. His surgery was remarkable for a dural tear that was repaired. He now presents with recurrence of his leg pain and back pain. Physical exam shows some mild erythema surrounding the incision. An MRI with and without gadolinium is performed and shown in Figure A and B. What is the most appropriate next step in management?
Continue routine postoperative care
Placement of a lumbar drain with a period of bedrest
Hospital admission, IV antibiotics, and serial ESR and CRP
CT guided aspiration
Surgical irrigation and debridement with commencement of antibiotics after cultures are obtained.
Select Answer to see Preferred Response
The clinical presentation and imaging studies are consistent with a postoperative surgical infection. Surgical irrigation and debridement is the most appropriate treatment.
Postoperative infections are one of the most common complications of lumbar spine surgery. Reports show a 0.7% infection rate with lumbar diskectomy with prophylactic antibiotics. It has been documented that the use of a microscope doubles this infection rate to 1.4%. The risk of infection is even higher with spinal fusion because of the presence of spinal instrumentation, with some studies showing an infection rate of up to 10%.
Sasso et al. review the diagnosis and management of postoperative spinal wound infections. They report the S aureus is the most common organism causing postoperative spinal infections and account for > 50% of cases. Other organisms found in these infections include S epidermidis, Peptococcus, Enterobacter cloacae, and Bacteroides. They report preoperative antibiotic prophylaxis decreases the infection rate for all scenarios.
Cousins et al. review MRI imaging of the spine. They report a gadolinium-containing contrast enhancement is used to distinguish scar tissue, which enhances on MRI scans, from fragments of disk tissue in the epidural space that, lacking capillaries, do not enhance. In the patient with spinal infection, contrast medium administration shows enhancement in affected vertebral bodies and abscesses.
Figure A show a sagittal T1-weighted MR. Figure B shows a sagittal T1-weighted MR image obtained of the lumbar spine after intravenous administration of gadolinium. These studies demonstrate abnormal edema (white arrows in A and B) and enhancement in the L4 and L5 vertebral bodies (open white arrows in B) and intervertebral disc (white arrowhead in B), with partial destruction of the endplate (black arrows).
Answer 1: The clinical presentation is consistent with an infection which should be treated.
Answer 2: Placement of an lumbar drain is indicated with a persistent CSF leak that has failed multiple repair attempts.
Answer 3: IV antibiotics alone is not the appropriate treatment of a lumbar surgical infection.
Answer 4: A CT guided aspiration is not indicated.
Sasso RC, Garrido BJ.
J Am Acad Orthop Surg. 2008 Jun;16(6):330-7. PMID: 18524984 (Link to Abstract)
Sasso, JAAOS 2008
Cousins JP, Haughton VM.
J Am Acad Orthop Surg. 2009 Jan;17(1):22-30. PMID: 19136424 (Link to Abstract)
Cousins, JAAOS 2009
Please rate question.
Average 3.0 of 23 Ratings
A 62-year-old man presents with 6 months of bilateral buttock and leg pain that is worse with prolonged standing and relieved with sitting. He denies symptoms with exercise on a stationary bike. Initial treatment including physical therapy, NSAIDS, and an epidural steroid injection provided only temporary relief of his symptoms, which have returned and are now severe. On physical exam he has normal motor strength in his lower extremities, negative straight-leg raise tests bilaterally, and palpable bilateral dorsalis pedis pulses. Lumbar flexion-extension radiographs show no spondylolisthesis or instability. A sagittal and axial T2 MRI is shown in Figure A and B, respectively. What is the most appropriate next step in management?
A decompressive laminectomy with bilateral medial facetectomies and foraminotomies
A decompressive laminectomy, bilateral medial facetectomies and foraminotomies, and an instrumented fusion
A left sided microdiskectomy
Continues physical therapy
Referral to vascular surgery for evaluation for peripheral vascular disease
The clinical presentation and imaging studies are consistent with neurogenic claudication due to spinal stenosis, WITHOUT degenerative spondylolisthesis on flexion and extension radiographs. The patient has already failed an initial attempt at nonoperative management, and therefore a decompressive laminectomy is the most appropriate next step in management.
Classic symptoms of lumbar spinal stenosis include heaviness and pain in the buttocks and legs that is worse with standing, walking, or extension of the back, and relieved with sitting and flexing the back. Symptoms are not relieved by going from walking to standing still upright, as they are in vascular claudication.
Weinstein and the SPORT investigators published that patients with at least 12 weeks of symptoms from spinal stenosis, without spondylolisthesis, had better outcomes with surgical decompression than with nonoperative management.
Atlas and the Maine Lumbar Spine Study Group found similar results. In both studies patients had improved outcomes with surgical treatment of lumbar spinal stenosis over four years compared to nonsurgical management.
Answer 2: A lumbar fusion is indicated for degenerative spondylolisthesis or segmental instability, neither of which this patient has.
Answer 3: The patient has spinal stenosis due to ligamentum flavum hypertrophy and bilateral facet arthrosis, and therefore a microdiskectomy would not provide adequate decompression.
Answer 4: The patient has already failed a trial of nonoperative management, and his symptoms remain severe, and therefore surgery is indicated.
Answer 5: Vascular claudication due to peripheral vascular disease is characterized by pain with activity, such as walking or cycling, that improves with rest, including standing upright. This patient's symptoms are not consistent with vascular claudication, and therefore referral to vascular surgery is not indicated.
Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H; SPORT Investigators.
N Engl J Med. 2008 Feb 21;358(8):794-810. doi: 10.1056/NEJMoa0707136. PMID: 18287602 (Link to Abstract)
Weinstein, NEJM 2008
Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE.
Spine (Phila Pa 1976). 2000 Mar 1;25(5):556-62. PMID: 10749631 (Link to Abstract)
Atlas, SPINE 2000
Average 3.0 of 32 Ratings
A 68-year-old man presents with bilateral buttock and leg pain, worse on the right. His pain is worse with prolonged standing and improves with sitting. His symptoms have progressed to the point that it is now difficult for him to walk to the mailbox. His physical exam is remarkable for 4/5 weakness to ankle dorsiflexion on the right. Four months of physical therapy and a series of epidural corticosteroid injections failed to improve his symptoms.
Figure A and B are an AP and lateral lumbar spine radiograph. Figures C and D are flexion/extension radiographs. Figure E is a sagittal MRI, and Figure F is an axial MRI through L4/5. The axial images through L3/4 and L5/S1 do not demonstrate any signs of significant nerve root compression.
What is the most appropriate next step in treatment?
Continued physical therapy
L4/5 microdiskectomy with a midline approach
L4/5 microdiskectomy with a Wiltse far lateral approach
L4/5 laminectomy, bilateral lateral recess decompression and foraminotomies
L4/5 laminectomy, bilateral lateral recess decompression and foraminotomies, and instrumented fusion
The clinical presentation is consistent with lumbar spinal stenosis without spondylolisthesis or instability. If nonoperative modalities have failed and the symptoms are severe, the a lumbar decompression with laminectomy, lateral recess decompression, and foraminotomies is indicated.
Weinstein et al. performed a prospective randomized trial comparing operative vs. nonoperative treatment for lumbar spinal stenosis. In the as-treated analysis, they reported a significant advantage for surgery at both 3 months and 2 years.
Atlas et al. evaluated the long term outcome of treatment options for lumbar spinal stenosis. They found that leg pain and back-related functional status were better in patients treated with surgery.
Figure A and B show an AP and lateral radiograph of the lumbar spine with degenerative changes. Figure C and D show flexion and extension radiographs with no evidence of instability or degenerative spondylolisthesis. Figure E is a sagittal T2-weighted MRI that shows spinal stenosis at L4/5, and Figure F is the axial MRI through L4/5 demonstrating spinal stenosis. Illustration A shows the hypertrophic ligamentum flavum and disc bulge at the affected level. Illustration B shows the proper steps of a decompressive laminectomy.
Answer 1: Nonoperative modalities have been attempted and have failed. His symptoms are severe enough to warrant surgical treatment.
Answer 2&3. This patient has spinal stenosis due to ligamentum flavum hypertrophy and facet hypertrophy. A microdiskectomy, regardless of approach, would not be effective.
Answer 5: The flexion extension radiographs show no evidence of segmental instability of spondylolisthesis, therefore a fusion would not be indicated.
Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE
Spine. 2005 Apr;30(8):936-43. PMID: 15834339 (Link to Abstract)
Atlas, SPINE 2005
Average 3.0 of 35 Ratings
A 62-year-old female has a decompressive laminectomy for spinal stenosis and symptoms of right leg pain. Preoperative flexion and extension radiographs of the lumbar spine are shown in Figure A. A preoperative sagittal MRI is shown in Figure B. Following surgery she reports no significant improvement in her right leg pain. What is the most likely cause of her residual leg pain.
Recurrent disk herniation
Residual foraminal stenosis
Cauda equina syndrome
Residual foraminal stenosis due to inadequate decompression is the most common explanation for persistent symptoms of leg pain following decompressive laminectomy for spinal stenosis.
The differential diagnosis for patients who have undergone previous spinal surgery but have persistent back and leg pain is large and includes (but is not limited to) recurrent neural compression, instability, recurrent herniation, infection, and cauda equina syndrome. These can be placed in two groups: 1) those in whom recurrent difficulties develop after initial symptom relief and 2) those have no interval improvement. Inadequate neural decompression results in no substantial improvement post-op as described in this question. Foraminal stenosis is technically challenging and is more likely to be the cause of residual compression.
Deen et al found the most common pattern in patients with early failure after laminectomy was the absence of neurogenic claudication and severe stenosis on preoperative imaging. They also found that the most common technical error was inadequate neural decompression.
Phillips et al emphasizes the need for a meticulous workup to identify the source of symptoms in this patient group. They argue in the absence of profound or progressive neurologic deficits, most patients with chronic back and leg pain who have undergone previous spinal surgery should be treated nonoperatively.
Figure A shows flexion-extension radiographs with no evidence of instability. Figure B is a T2-weighted sagittal MRI showing spinal stenosis at L4/5 due primarily to ligamentum hypertrophy. Illustration A shows the steps to a decompressive laminectomy. The foramen of both the exiting and descending nerve roots should be probed to ensure an adequate foraminal decompression.
Answer 1: Segmental instability is a common cause of persistent back and leg pain in patients who have degenerative spondylolisthesis treated with decompression alone. This patient has no evidence of listhesis on preoperative flexion-extension films.
Answer 2: Infection will likely develop slowly over time after a pain-free interval and likely involve axial pain rather than extremity pain.
Answer 3: Disk herniation and instability should be considered post-op if symptoms recur after a pain-free interval of months to years.
Answer 5: Cauda equina syndrome will present in the immediate postoperative period and is very rare and presents with saddle anesthesia and bowel and bladder symptoms.
Phillips FM, Cunningham B.
Spine (Phila Pa 1976). 2002 Nov 15;27(22):2547-53; discussion 2554. PMID: 12435991 (Link to Abstract)
Phillips, SPINE 2002
Deen HG Jr, Zimmerman RS, Lyons MK, Wharen RE Jr, Reimer R.
Mayo Clin Proc. 1995 Jan;70(1):33-6. PMID: 7808047 (Link to Abstract)
Average 4.0 of 29 Ratings
During lumbar decompression at L4/5, which of the following decompression techniques will destabilize the spine and require a L4/5 fusion.
Removal of > 50% of the L4/5 nucleus pulpusus
Removal of the L4 and L5 spinous process and interspinous ligament
A medial facetectomy removing 20% of the right L4/5 facet joint
Bilateral resection of the L4 inferior articular process
A unilateral hemilaminectomy
Bilateral resection of the L4 inferior articular process will destabilize the spine.
Abumi et al in an in vitro experiment using fresh human lumbar functional spinal units, found that total facetectomy, even created unilaterally, makes the lumbar spine unstable. They also found that medial facetectomy and division of the posterior ligaments (consisting of the supraspinous/interspinous ligaments) did not destabilize the spine.
Lee et al, in another anatomic study, that found unilateral facetectomy and resection on the contralateral facet markedly alters the rotational motion and destabilizes the spine.
Illustration A demonstrates the key components of a lumbar single level laminectomy. The region of a bilateral resection of the L4 inferior articular process is highlighted in red.
Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ.
Spine (Phila Pa 1976). 1990 Nov;15(11):1142-7. PMID: 2267608 (Link to Abstract)
Abumi, SPINE 1990
Lee KK, Teo EC, Qiu TX, Yang K
Spine. 2004 Aug;29(15):1624-31. PMID: 15284506 (Link to Abstract)
Lee, SPINE 2004
Average 4.0 of 20 Ratings
A dural tear occurs during a routine lumbar laminectomy for spinal stenosis. A water-tight repair is subsequently performed. How will this affect postoperative care and ultimate clinical outcomes?
there is an increased risk of wound infection
the patient must remain flat in bed for seven days
the clinical outcome will not be affected
the patient will have a worse clinical outcome
the patient should remain on PO antibiotics for ten days following surgery
Dural tears are more common during revisions, but they can almost always be repaired primarily, with a good or excellent outcome and without additional complications. Closed suction wound drainage does not seem to aggravate the leak and can be used safely in the presence of a dural repair.
The cited reference by Wang et al agrees with prior studies and found that an unintended incidental durotomy resulted in no substantial difference in the final outcomes of operative procedures on the lumbar spine. Therefore, Wang et al concluded that a dural tear does not adversely influence the long-term results of operations on the lumbar spine.
Wang JC, Bohlman HH, Riew KD.
J Bone Joint Surg Am. 1998 Dec;80(12):1728-32. PMID: 9875930 (Link to Abstract)
Wang, JBJS 1998
Average 4.0 of 24 Ratings
Patients with symptomatic spinal stenosis treated with surgical decompression compared to those treated nonoperatively have what clinical outcomes.
Worse clinical outcomes at four years
No difference in clinical outcomes at four years
Improved clinical outcomes in pain only at four years
Improved clinical outcomes in function only at four years
Improved clinical outcomes in pain and function at four years
Recent studies show patients with symptomatic spinal stenosis treated with surgical decompression have improved clinical outcomes in pain and function at four years compared to those treated without surgery.
The Spine Patient Outcomes Research Trial (SPORT) is a multi-center randomized controlled trial (RCT) comparing surgical and non-surgical treatment for patients with lumbar disc herniations, lumbar spinal stenosis, and degenerative spondylolisthesis. Results of the randomized cohort were disrupted by a high cross-over rate between the surgical and nonsurgical groups. Therefore, they conducted "as-treated" statistical analysis as a prospective cohort study (non-randomized). Based on the as-treated analysis, two year and four year results for spinal stenosis show improved clinical outcomes in pain and function.
Atlas et al in the Maine Lumbar Spine Study (MLSS) also showed "surgical treatment was associated with greater improvement in patient-reported outcomes than nonsurgical treatment at 4-year evaluation."
Katz et al showed that in patients treated with surgery for lumbar stenosis, those with greater medical comorbidiity, functional disability, and increased back pain relative to leg pain were significantly less satisfied with the results of surgery.
Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H.
Spine (Phila Pa 1976). 2010 Jun 15;35(14):1329-38. PMID: 20453723 (Link to Abstract)
Weinstein, SPINE 2010
Katz JN, Lipson SJ, Brick GW, Grobler LJ, Weinstein JN, Fossel AH, Lew RA, Liang MH.
Spine (Phila Pa 1976). 1995 May 15;20(10):1155-60. PMID: 7638658 (Link to Abstract)
Katz, SPINE 1995
Average 4.0 of 18 Ratings
A 32-year-old man underwent a lumbar microdiskectomy and an incidental dural tear occurred. A hemilaminectomy was performed to obtain adequate visualization of the defect, and primary repair of the tear was performed. One month postoperatively he returns to the office complaining of severe headaches and occasional nausea which is worse with standing. He denies fever or chills. On physical exam his wound is well healed with no cellulitis or erythema. WBC and ESR are within normal limits. What is the most likely diagnosis?
Cerebrospinal fluid leak
The clinical scenario is consistent with a persistent cerebral spinal fluid leak due to an intraoperative dural tear.
The incidence of dural tears during spine surgery vary between 2-17%. In patients in the postoperative period, if there is suspicion of a dural leak, an MRI should be performed to look for a CSF leak. Once the diagnosis is confirmed, the gold standard treatment is reoperation. Less invasive methods of treatment include percutaneous fibrin glue, subarachnoid drainage or an epidural blood patch. If these fail to relieve symptoms, reoperation is mandatory.
Bosacco et al showed headaches and nausea when standing up after spinal surgery are classic symptoms for dural tears and cerebrospinal fluid leaks. Other symptoms include photophobia, posterior neck pain, nausea, and vertigo classically worse when standing or sitting.
Wang et al found an increased incidence of dural tears with revision surgery. They found that a dural tear, if repaired properly, does not appear to have any long-term deleterious effects or to increase the risk of postoperative infection, neural damage, or arachnoiditis.
Bosacco SJ, Gardner MJ, Guille JT.
Clin Orthop Relat Res. 2001 Aug;(389):238-47. PMID: 11501817 (Link to Abstract)
Bosacco, CORR 2001
Average 3.0 of 21 Ratings
A 71-year-old female is admitted to the hospital for severe bilateral buttock and leg pain with ambulation that has failed to improve with nonoperative management. An MRI is shown in Figure A. You plan on proceeding with lumbar decompression. What is the most powerful preoperative prognostic factor for clinical outcomes with surgical treatment of this condition.
Anterior compression due to disc herniation
Comorbid medical conditions
Average household income
The clinical presentation and imaging studies supports the diagnosis of lumbar spinal stenosis. Comorbid medical conditions is the most powerful preoperative prognostic factor for clinical outcomes with surgical treatment of this condition.
The study by Mofidi et al found a direct relationship between poor outcome and coexisting medical conditions.
The 1999 study by Katz et al found the most powerful preoperative prognostic factors were the patient’s own assessment of good or excellent preoperative health and comorbidity.
The 1991 study by Katz et al found that medical co-morbidity including osteoarthrosis, cardiac disease, rheumatoid arthritis, or chronic pulmonary disease are risk factors for a poor outcome.
The SPORT study by Weinstein et al, which is a large multicenter prospective study, supported earlier studies that patients with spinal stenosis have improved outcomes in pain and function when treated with surgery compared to those treated without surgery.
Mofidi A, O'Connor D, El-Abed K, McCabe JP.
J Spinal Disord Tech. 2002 Oct;15(5):377-83. PMID: 12394661 (Link to Abstract)
Katz JN, Stucki G, Lipson SJ, Fossel AH, Grobler LJ, Weinstein JN.
Spine (Phila Pa 1976). 1999 Nov 1;24(21):2229-33. PMID: 10562989 (Link to Abstract)
Katz, SPINE 1999
Katz JN, Lipson SJ, Larson MG, McInnes JM, Fossel AH, Liang MH.
J Bone Joint Surg Am. 1991 Jul;73(6):809-16. PMID: 2071616 (Link to Abstract)
Katz, JBJS 1991
Average 2.0 of 51 Ratings
This video demonstrates how to measure and ankle-brachial index.
HPI - 75yo F w h/o L4-L5 L5-S1 laminectomy and discectomy several years ago without instrumented fusion presents complaining of severe axial lumbar pain of increasing intensity x 2 years despite physical therapy. She was seen by a Neurosurgeon who recommended no surgical intervention.
Non-operative vs operative?