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A 70-year-old woman is seen back in follow-up in your clinic with persistent shooting pains down the back of her legs, which have been increasing over the last nine months. She can walk for about 3 minutes before the pain becomes unbearable. It is relieved only when she sits down or bends forward. Her neurological exam demonstrates difficulty with heel-walking and normal patellar tendon reflexes bilaterally. Pedal pulses are present. Figures A and B show a lateral x-ray and a sagittal MRI of her lumbar spine. She has failed all previous conservative management and would like to proceed with surgery. What is the most appropriate treatment?
Vascular surgery consult
Anterior lumbar interbody fusion
Laminectomy and instrumented fusion
Laminectomy and uninstrumented fusion
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A 44-year-old male presents with pain in the posterior aspect of his left thigh after walking more than 20 feet. Figures A demonstrates an upright lateral lumbar spine radiograph. Figure B is a sagittal MRI image and Figure C is an axial image through L4/5. He has failed physical therapy, anti-inflammatory medications and three epidural steroid injections. After he undergoes the appropriate surgery, which of the following places him at the highest risk for adjacent segment disease requiring future surgery?
Adjacent level laminectomy
Undergoing a one level fusion
A 65-year-old male presents for postoperative follow up after undergoing spinal surgery. His preoperative and postoperative radiographs are shown in Figure A and B respectively. His past medical history is significant for osteoarthritis, hypertension, and smoking 1.5 packs per day for greater than 35 years. Which variable in this patient’s history has been reported to be associated with lower functional outcomes after this surgery?
Age > 60 years old
A 57-year-old woman with a past medical history of diabetes mellitus and arrythmias, requiring prior insertion of a pacemaker, presents with severe bilateral leg pain for 12 months. She reports the symptoms are worse with prolonged walking and improved with sitting. The severity of her symptoms has led her to exercise primary on a stationary bicycle, which she reports does not cause her symptoms. On physical exam she is neurologically intact in her lower extremities. She has an ABI of 0.95. A flexion and extension radiograph is performed and shown in Figure A. An axial CT myelogram at the L4/5 level is shown in Figure B. Extensive nonoperative treatment with therapy and epidural steroid injections have failed to provide any relief of her symptoms. What would be the most appropriate next step in treatment?
Obtain magnetic resonance imaging
Refer the patient to a vascular surgeon for treatment of peripheral vascular disease
Proceed with a lumbar decompression
Proceed with a lumbar decompression and instrumented fusion
Proceed with a lumbar decompression and uninstrumented fusion
A 71-year-old male presents with bilateral leg pain for the last two years. His pain is exacerbated when walking and is relieved when his sits or bends forward. He notes occasional periods where his legs feel weak, but motor examination reveals 5/5 motor strength throughout his bilateral lower extremities. He has diminished sensation on the medial aspect of his feet bilaterally. Management thus far has included NSAIDS with occasional narcotic usage, physical therapy, and two epidural steroid injections. Figure A shows a flexion radiograph, Figure B shows an extension radiograph, and Figures C and D show his current MRI scan. He feels his pain is substantially worse than it was one year ago. What is the most appropriate management at this time?
Posterior L4-5 laminectomy, wide decompression, and foraminotomy
Posterior L4-5 decompression with arthrodesis
L5-S1 decompression and uninstrumented fusion
A 59-year-old male presents with worsening bilateral buttock and leg pain that is worse with prolonged standing and improves with sitting. His symptoms have worsened to the point that it is now difficult for him to walk small distances. Physical exam shows weakness to EHL on the right. A magnetic resonance image is shown in Figure A. Nonsurgical management, including epidural corticosteroid injections, has failed to relieve the patient’s symptoms. What is the most appropriate next step in management?
Continued nonsurgical management
Decompressive laminectomy alone
Right side microdiskectomy
Decompressive laminectomy with posterior instrumented fusion
A 62-year-old female presents with one year of severe back and bilateral buttock pain. Her symptoms are worse with walking and improve with sitting. She now finds it difficult to walk even small distances, such as to her mailbox. Six months of nonoperative management including physical therapy, oral medications, and epidural corticosteroid injections have failed to provide lasting relief of her symptoms. Flexion and extension lateral radiographs are shown in Figures A and B. Sagittal and axial MRI images are shown in Figure C and D. What is the next most appropriate step in mangement?
EMG to confirm a lumbar radiculopathy
A far-lateral microdiskectomy on the left
A lumbar total disc replacement
Lumbar laminectomy with partial facetectomy and foraminotomy
Lumbar laminectomy with partial facetectomy, foraminotomy, and instrumented posterior spinal fusion
A 47-year-old male underwent L4-5 posterior lumbar decompression and fusion with instrumentation. At the six-week clinical visit he complains of pain in the region of his wound. On physical exam there is wound erythema but no exudate. Laboratory studies show an erythrocyte sedimentation rate of 78 mm/h (normal up to 20 mm/h) and WBC count of 11,200/mm3 (normal 3,500 to 10,500/mm3). An MRI is perfomed and shows a fluid collection dorsal to the thecal sac. What is the most appropriate next step in management?
CT guided aspiration of the fluid collection and cultures
Surgical debridement followed by delayed closure and retention of instrumentation
Surgical debridement followed by delayed closure and removal of instrumentation
Parenteral Cephalexin for 10 days followed by repeart laboratory studies
Broad spectrum intravenous antibiotics for 6 weeks followed by repeart laboratory studies
A 60-year-old male presents with severe low back pain and pain and numbness in his buttocks with prolonged standing. His pain improves with forward bending. Lateral radiographs with flexion and extension reveal L4/5 spondylolisthesis with mobility. MRI shows significant spinal stenosis. Six months of nonoperative management, including epidural corticosteroid injections has failed. The next step in treatment should consist of?
Lumbar disc arthroplasty
Lumbar decompression and fusion
Lumbar decompression only
Lumbar fusion only
In patients with degenerative spondylolisthesis undergoing posterolateral fusion, use of pedicle screws has been shown to confer which of the following effects?
Have no effect on the rate of pseudoarthosis
Decrease the rate of pseudoarthrosis
Increase the level of postoperative pain at one year
Increase patient satisfaction with the procedure
Decrease the rate of postoperative infection
Lateral Transpsoas Surgery Vinko Zlomislic, M.D. (COA 2017, 4.4)
The Spine Bone is Connected to the Hip Bone: The Importance of Sagittal Balance...
HPI - low back pain radiating to b/l lower limb (L>R)since 9 months
Associated numbness in b/l lower limb below L2.
Pain aggravated by bending forward, with activities.
normal bowel/bladder habits
How would you treat this patient as a FIRST LINE of treatment?
HPI - The patient has a history of spinal stenosis at L3/4 that was treated with a bilateral foraminotomy and disckectomy at L3/4 and L4/5 back in 2013.
The patient did well for a year or two but now has worsing bilateral buttock pain that extend down to the posterior aspect of his knees. His symptoms are worse with prolonged walking and improve with sitting. His symptoms have worsened to the point that he is unable to walk long distances.
He also complains of urinary "leaking".
How would you treat this patient?