summary Lumbar Disc Herniation is a very common cause of low back pain and unilateral leg pain, known as radiculopathy. In rare cases a large disc herniation can lead to Cauda Equina Syndrome which requires emergent diagnosis and treatment. Diagnosis is made clinically and confirmed with an MRI studies of the lumbar spine. Treatment for radicular leg pain is initially nonoperative with oral medications and physical therapy. Surgical microdiscectomy is only indicated for severe pain and/or motor deficit that have failed to respond to nonoperative management. Treatment for Cauda Equina Syndrome in contrast is emergent microdiscectomy within 48 hours. Epidemiology Incidence peak incidence is 4th and 5th decades lifetime prevalence of 10% only ~5% become symptomatic Demographics 3:1 male:female ratio Location L5/S1 most common level 95% involve L4/5 or L5/S1 levels Etiology Pathoanatomy recurrent torsional strain leads to tears of the outer annulus which leads to herniation of nucleus pulposis lateral edge of posterior longitudinal ligament weakest region common site for posterolateral/paracentral disc herniations sinuvertebral nerves provide pain innervation to the posterior annulus mediate vertebrogenic back pain that precedes or accompanies disc herniation Pathophysiology cellular senescence of fibrochondrocytes leads to loss of proteoglycan production leading to disc height loss loss of height causes increased strain on the annulus fibrosus increased strain leads to fissures of the annulus fibrils annular tears compromise hoop stresses that act against the deforming forces of the nucleus pulposus nucleus pulposus herniates through tear younger, well-hydrated discs more likely to herniate pediatric patients may have Salter-Harris II fracture of the ring apophysis older, desiccated discs less likely to herniate sciatica symptoms result from combined mechanical compression and associated inflammation not all patients with mechanical compression develop symptoms TNF-α, MMP, NO, PE2, and IL-6 are implicated in nerve irritation leading to radiculopathy weak evidence to support DMARDs for treatment Anatomy Complete intervertebral disc anatomy and biomechanics Disc composition annulus fibrosis composed of type I collagen, water, and proteoglycans 15-25 sheets of lamellae characterized by extensibility and tensile strength high collagen / low proteoglycan ratio (low % dry weight of proteoglycans) nucleus pulposus composed of type II collagen, water, 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 polysaccharide content and high water content (88%) disc height dependent on the degree of hydration avascular structure nutrients supplied by diffusion from the end plates 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) less common (5-10%) affects exiting/upper nerve root at L4/5 affects L4 nerve root herniated disc material directly compresses dorsal root ganglion can manifest with more severe pain than traditional posterolateral disc herniation axillary can affect both exiting and descending nerve roots Morphology 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 prone to proximal or distal migration Containment classification contained disc material is contained beneath the posterior longitudinal ligament uncontained disc material passes dorsal to the posterior longitudinal ligament Timing classification acute herniations present < 3-6 months important consideration given surgical outcomes are associated with chronicity chronic herniations present >6 months Presentation History sudden onset of pain after lifting a heavy object occupational exposure prolonged sitting with lateral bending and rotation in the presence of vibrational energy symptomatic improvement lying supine with knees and hips flexed especially with lower lumbar disc herniations Symptoms can present with symptoms of axial back pain (low back pain) this may be discogenic or mechanical in nature can precede herniation radicular pain (buttock and leg pain) often worse with sitting, improves with standing symptoms worsened by coughing, valsalva, sneezing pain not worsened with ambulation cauda equina syndrome (present in 1-10%) bilateral leg pain LE weakness saddle anesthesia bowel/bladder symptoms Physical exam inspection limited lumbar range of motion often the pain is the limiting factor patient leaning away from side of radiculopathy effort to increase the size of the neuroforamen palpation spasms of the paraspinal musculature nonspecific associated tenderness in the paraspinal musculature nonspecific motor exam & reflexes see lower extremity neuro exam L3 radiculopathy hip adduction weakness knee extension weakness dermatomal pain in the anteromedial thigh L4 radiculopathy ankle dorsiflexion weakness (L4 > L5) decreased patellar reflex dermatomal pain in the lateral thigh, crossing the knee, to medial foot L5 radiculopathy EHL weakness (L5) manual testing ankle dorsiflexion weakness (L4 > L5 contribution) test by having patient walk on heels ankle inversion weakness hip abduction weakness (L5) have patient lie on side on exam table and abduct leg against resistance dermatomal pain in anterolateral leg and dorsum of foot S1 radiculopathy ankle plantar flexion weakness (S1) have patient do 10 single leg toes stands decreased Achilles tendon reflex dermatomal pain in posterior calf and lateral foot provocative tests straight leg raise (Lasegue's sign) a tension sign for L4, 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 femoral nerve stretch test (Wasserman sign) tension sign for L2 and L3 performed in prone position knee flexed and hip exteneded reproduction of pain in anterior thigh is considered positive Braggard's sign perform SLR to the point of exacerbation lower leg just to the point where pain recedes ankle dorsiflexion causes exacerbated pain 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 recommended views AP and lateral radiographs helpful for surgical localization identify anomalous vertebrae (sacralized L5 or lumbarized S1) optional views flexion-extension identifies instability if present can changes surgical plan to involve fusion findings most often normal abnormal findings loss of lordosis (spasm) loss of disc height especially at the involved level lumbar spondylosis (degenerative changes) facet hypertrophy disc space collapse peridiscal osteophytes sciatic scoliosis convex or concave list to the ipsilateral side of herniation sensitivity poor sensitivity for identifying disc herniation more often used as a screening tool for other pathology prior to proceeding with MRI CT myelogram indications patients unable to obtain MRI pacemaker views sagittal and coronal reconstructions demonstrate compression of the thecal sac findings myelography filling defect at the level of herniation a calcified disc may be visible sensitivity 93% accurate at detecting associated surgical pathology unable to detect foraminal or extraforaminal herniations MRI without gadolinium 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) modality of choice for diagnosis of lumbar 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 need to correlate MRI findings with symptoms and physical exam findings views sagittal and coronal T2 reconstructions localize the level and side of the herniation location anatomic location (central vs paracentral vs foraminal vs extraforaminal) MRI with gadolinium indications useful for revision surgery findings 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, anti-inflammatory medications, and limited narcotics indications first line of treatment for most patients with disc herniation new-onset radicular pain no significant motor weakness absence of cauda equina syndrome no bowel/bladder incontinence technique bedrest followed by progressive activity as tolerated historically treatment most modern protocols involve immediate activity with modification to avoid pain exacerbation medications NSAIDS muscle relaxants (more effective than placebo but have side effects) oral steroid taper modest but significant improvement in function, no significant improvement in pain physical therapy typically initiated three weeks after symptom onset extension exercises are extremely beneficial traction chiropractic manipulation narcotic medications typically avoided due to complication profile if used, usually for a short period (2-3 days) in the acute setting outcomes 90% improve without surgery positive predictors of good outcomes with nonoperative treatment higher level of education selective nerve root corticosteroid injections indications second line of treatment if therapy and medications fail usually after 6 weeks technique epidural selective nerve block can be therapeutic and diagnostic 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 no difference in pain relief using lidocaine with and without steroids Operative laminotomy and discectomy (microdiscectomy) indications persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections) timing of appropriate nonoperative treatment varies better surgical outcomes if addressed within 2 months progressive and significant weakness cauda equina syndrome technique various techniques available most techniques can be performed in a "minimally invasive" fashion can be done with small incision or through "tube" access open technique using a crank (McCulloh) retractor discectomy performed through microscope or loupe magnification no difference in outcomes between the two endoscopic techniques available provide smaller incisions similar outcomes between all techniques surgical techniques fragment excision vs extended disc space curettage (subtotal discectomy) lower long term back pain with fragment excision higher reherniation rates with fragment excision at 2-years follow-up 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 early and sustained pain relief out to 2 years equal likelihood of receiving disability at 5 years 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 progressively worsening symptoms prior to surgery professional athletes younger age, greater number of games played prior to injury paracentral and foraminal herniations central and extraforaminal associated with worse outcomes herniation at caudal levels L5-S1 results in better outcomes than L2-3 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 smokers chronic headaches depression far lateral microdiskectomy indications for far-lateral disc herniations technique utilizes a paraspinal approach of Wiltse can also be done with tubular or crank retractors Techniques Rest and physical therapy, anti-inflammatory medications, and limited narcotics Complications Dural tear occurs in 0-4% of cases treatment if have tear at time of surgery then perform water-tight repair has not been shown to adversely affect long term outcomes Recurrent HNP defined as recurrent sciatica at the same operated level pain-free interval of 6 months prior to recurrence of symptoms pathology can be ipsilateral to contralateral to the index presentation recurrence rate 5-15% revision rate at 8-year follow-up is 15% according to the SPORT trial risk factors protective against recurrent herniation discrete herniations small annular defects (<6 mm) treatment can treat nonoperatively initially revision microdiscectomy in patients with persistent symptoms outcomes for revision discectomy have been shown to be as good as for primary discectomy Wound infections occurs in up to 3% of cases epidural abscess in 0.3% of cases risk factors microscope usage proposed as a source of infection some date refutes this claim treatment superficial infections treat with local wound care and antibiotics deep infections surgical I&D Epidural fibrosis scarring the compresses the dura leading to radicular symptoms associated with poor outcomes following revision surgery persistent back pain patients 3.2 times more likely to suffer from recurrent radiculopathy MRI may demonstrate retraction of the dura on the side of the lesion Pyogenic discitis occurs in 2.3% of cases treatment IV antibiotics +/- surgical I&D Chronic low back pain not completely understood but central sensitization may be a factor amplification of neural signaling within the central nervous system (CNS) that elicits pain hypersensitivity. Modic changes on MRI imaging are associated with post-operative back pain Pain diagrams may be useful in identifying patients with an increased likelihood of pain sensitization, psychosocial load, and utilizing pain management resources Vascular catastrophe exceedingly rare caused by breaking through anterior annulus and injuring vena cava/aorta treatment immediate recognition of complication followed by coordinated repair by vascular service Instability due to over resection of lamina and pars interarticularis not all patients are symptomatic treatment instrumentation and fusion of the affected segment Prognosis Natural history 90% of patients will have improvement of symptoms within 3 months without substantial medical treatment patients less likely to improve if still symptomatic after 6 weeks factors associated with good outcomes with nonoperative treatment lack of radiculopathy factors associated with worse outcomes with nonoperative treatment obese patients (BMI >30) symptoms present >6 months prior to starting treatment Size of herniation decreases over time (reabsorbed) sequestered disc herniations show the greatest degree of spontaneous reabsorption macrophage phagocytosis and enzymatic degradation is the mechanism of reabsorption Factors associated with favorable surgical outcomes severe preoperative leg pain shorter symptom duration younger age increased preoperative physical activity Surgical treatment is equivalent to nonsurgical treatment in the long term surgery provides faster pain relief
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Microdiscectomy Orthobullets Team Spine - Lumbar Disc Herniation
QUESTIONS 1 of 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.40) A 39-year-old seasoned professional football player sustains an injury to his lower back during off-season training. Figure 1 and 2 show the pertinent MRI findings. Which of the following is true? QID: 211542 FIGURES: A B Type & Select Correct Answer 1 Age at the time of injury is a positive predictor of career length and the ability to return to sport. 30% (420/1416) 2 Following this injury, the likelihood of remaining active within professional sports remains relatively constant over the first 2 years from injury. 37% (526/1416) 3 The number of games played prior to injury is a positive predictor of ability to return to play following this injury. 23% (324/1416) 4 This patient is more likely to return to play than players of another professional sport. 2% (34/1416) 5 This patient would experience less of a treatement effect from surgery compared to players of other professional sports. 7% (99/1416) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ18.95) A 44-year-old patient is presenting with right dorsal foot pain, loss of sensation, and weakness that started 3 weeks ago after moving large heavy boxes from his friend's apartment. Coughing and the Valsalva maneuver make the pain worse. Which physical exam finding would suggest peroneal nerve palsy instead of L5 radiculopathy? QID: 212991 Type & Select Correct Answer 1 Weak ankle plantarflexion 8% (153/1871) 2 Weak ankle dorsiflexion 35% (663/1871) 3 Intact ankle inversion 45% (837/1871) 4 Intact ankle eversion 10% (182/1871) 5 Weak knee extension 1% (24/1871) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18SP.62) Figure 1 is the axial MRI image of the L5-S1 level from a patient with weakness, and left leg pain. Which muscle function would be most likely to be affected in this patient? QID: 211784 FIGURES: A Type & Select Correct Answer 1 Hip flexion 2% (32/1734) 2 Hip adduction 3% (44/1734) 3 Hip abduction 49% (856/1734) 4 Knee Extension 5% (84/1734) 5 Ankle plantarflexion 41% (709/1734) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.271) A 45-year-old female returns to your clinic with 10-weeks of severe pain that starts in her back and extends down her right leg to the top of her foot. On physical exam she has decreased sensation on the dorsal aspect of her foot and 4/5 strength in her EHL. She has a positive straight leg raise on the right. The remaining physical exam is unremarkable, including normal achilles and patellar reflexes bilaterally, no clonus, and a down-going Babinski sign. Her pain has not been relieved by NSAIDs, epidural steroids or physical therapy. Figure A is a sagittal MRI and figure B is a axial MRI through the L4/5 disc space. What is the best treatment option at this time? QID: 4906 FIGURES: A B Type & Select Correct Answer 1 Continued oral anti-inflammatories 3% (84/3015) 2 Right L4/5 microdiscectomy 92% (2760/3015) 3 Right L4/5 minimally invasive transforaminal interbody fusion 1% (40/3015) 4 Referral for EMG and nerve conduction studies 1% (21/3015) 5 L4/5 posterior decompression and instrumented fusion 3% (91/3015) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ13.27) A 35-year-old physical therapist presents with right-sided back and leg pain. For the last 4 months, he has taken anti-inflammatory medications and performed exercises on his own. While his back pain has improved slightly, his leg pain remain severe and interferes with his ability to sleep and work. Examination reveals positive ipsilateral and contralateral straight leg raise at 30 degrees. He has mildly diminished big toe dorsiflexion strength on the right side. There is a small patch of diminished sensation on the dorsum of the foot. MRI scans are shown in Figures A and B. What is the most appropriate next step in treatment? QID: 4662 FIGURES: A B Type & Select Correct Answer 1 Continued rest, formal physical therapy and anti-inflammatory medications 5% (234/4323) 2 Targeted chemonucleolysis of the L4-5 disc 1% (33/4323) 3 Discectomy and interbody fusion L4-5 6% (254/4323) 4 Discectomy utilizing a midline approach between the spinous process and multifidus 72% (3129/4323) 5 Discectomy utilizing an intermuscular approach between multifidus and longissimus 15% (646/4323) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12SP.99) A 45-year-old man presents to clinic with low back and lower extremity pain. He also complains of weakness in the lower extremity. His MRI is shown in Figure A. Which muscle would you most likely expect to be weak in this patient? QID: 3797 FIGURES: A Type & Select Correct Answer 1 Extensor hallucis longus 4% (67/1817) 2 Tibialis anterior 77% (1393/1817) 3 Gastrocnemius 2% (30/1817) 4 Psoas major 17% (303/1817) 5 Flexor hallucis longus 1% (13/1817) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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. He reports pain and paresthesias to the right buttock, posterolateral lower leg and lateral foot. On strength testing, he has graded 5/5 strength to knee extension, 5/5 ankle dorsiflexion and 4/5 ankle plantar flexion. Flexion and extension radiographs show no evidence of spondylolisthesis. Sagittal and axial MRI images are shown in Figure A and B. Which of the following treatment modalities will allow the greatest improvement of physical functioning? QID: 4590 FIGURES: A B Type & Select Correct Answer 1 Observation alone 1% (36/3503) 2 Physical therapy 3% (96/3503) 3 Medical management with GABA analogs 1% (33/3503) 4 Discectomy 84% (2937/3503) 5 Disectomy and instrumented fusion 10% (361/3503) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12SP.14) A 36-year-old male presents with acute onset of right buttock and leg pain following lifting a heavy object. On physical exam he has weakness to knee extension, numbness over the medial malleolus, and a decreased patellar reflex. Which of the following would most likely explain this clinical presentation. QID: 3712 Type & Select Correct Answer 1 Lumbar arachnoiditis 0% (10/4819) 2 L4/L5 paracentral disc herniation 4% (181/4819) 3 L3/L4 far lateral (foraminal) disc herniation 17% (839/4819) 4 L4/L5 far lateral (foraminal) disc herniation 77% (3706/4819) 5 L5/S1 far lateral (foraminal) disc herniation 1% (56/4819) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12SP.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? QID: 3706 FIGURES: A Type & Select Correct Answer 1 Equal limb pain and equal functional outcomes 55% (2957/5350) 2 Improved limb pain and improved functional outcomes 11% (595/5350) 3 Worsened limb pain and worsened functional outcomes 15% (808/5350) 4 Worsened limb pain but improved functional outcomes 1% (80/5350) 5 Improved limb pain but worsened functional outcomes 16% (879/5350) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 4462 Type & Select Correct Answer 1 Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35 8% (348/4562) 2 Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35 18% (825/4562) 3 Age > 41 years, divorced, presence of worker compensation claim 1% (47/4562) 4 Age < 31 years, absence of joint problems, no workers compensation 37% (1682/4562) 5 Age > 41 years, absence of joint problems, married status 36% (1622/4562) L 5 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3659 Type & Select Correct Answer 1 Left L2-3 foraminal herniated nucleus pulposis 8% (327/3884) 2 Left L4-5 central herniated nucleus pulposis 3% (122/3884) 3 Left L4-5 paracentral herniated nucleus pulposis 11% (408/3884) 4 Left L4-5 foraminal herniated nucleus pulposis 76% (2950/3884) 5 Left L5-S1 paracentral herniated nucleus pulposis 1% (53/3884) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 3488 FIGURES: A B Type & Select Correct Answer 1 L4/5 microdiskectomy through midline approach 70% (2486/3537) 2 L4/5 microdiskectomy with far lateral Wiltse approach 7% (243/3537) 3 L4/5 Decompression, TLIF, and instrumented fusion 7% (252/3537) 4 L4/5 Decompression, PLIF, and instrumented fusion 14% (479/3537) 5 L4/5 Anterior Lumbar Interbody Fusion 1% (48/3537) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 3106 Type & Select Correct Answer 1 Equivalent relief from symptoms and equivalent improvement in quality of life 3% (70/2518) 2 Less relief from symptoms and less improvement in quality of life 67% (1695/2518) 3 Improved relief from symptoms and greater improvement in quality of life 2% (44/2518) 4 Significantly decreased return to work status 26% (666/2518) 5 Significantly improved return to work status 1% (30/2518) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3019 FIGURES: A B Type & Select Correct Answer 1 Refer the patient to pain management 0% (9/2923) 2 Repeat epidural steroid injection 1% (16/2923) 3 Transforaminal diskectomy 8% (240/2923) 4 Laminotomy and diskectomy 87% (2553/2923) 5 Spinal fusion with interbody cage and posterior instrumentation 3% (89/2923) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE08AN.31) What structure is located at the tip of the arrow in Figure 18? QID: 6191 FIGURES: A Type & Select Correct Answer 1 Left L3 nerve root 3% (22/663) 2 Right L3 nerve root 79% (523/663) 3 Right L4 segmental artery 8% (52/663) 4 Right L4 nerve root 9% (58/663) 5 Left lateral disk herniation 0% (2/663) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 544 Type & Select Correct Answer 1 Worse outcomes in pain, physical function, and return to work status at 4 years. 3% (58/1974) 2 Equivalent outcome in pain and physical function at 4 years. 40% (795/1974) 3 Improved outcome in pain and physical function at 4 years. 50% (991/1974) 4 Improved outcome in return to work status only at 4 years. 1% (27/1974) 5 Worse outcome in return to work status with equivalence in pain and physical function at 4 years. 5% (90/1974) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 154 FIGURES: A Type & Select Correct Answer 1 Microdiskectomy 7% (204/2977) 2 Posterior spinal fusion with instrumentation 1% (16/2977) 3 Decompression only 3% (75/2977) 4 Strict bedrest 1% (21/2977) 5 Anti-inflammatory medication and physical therapy 89% (2636/2977) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
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