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A decompressive laminectomy with bilateral medial facetectomies and foraminotomies
65%
2370/3635
A decompressive laminectomy, bilateral medial facetectomies and foraminotomies, and an instrumented fusion
27%
996/3635
A left sided microdiskectomy
3%
116/3635
Continues physical therapy
2%
73/3635
Referral to vascular surgery for evaluation for peripheral vascular disease
1%
49/3635
Select Answer to see Preferred Response
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. Incorrect Answers: 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.
3.4
(37)
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