Lumbar Disc Herniation

(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? Tested Concept

(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? Tested Concept

(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? Tested Concept

(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. Tested Concept

(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? Tested Concept

(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?

Tested Concept

(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? Tested Concept

(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? Tested Concept

(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? Tested Concept

(OBQ09.235) 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 Tested Concept

(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? Tested Concept

(SAE08AN.31) What structure is located at the tip of the arrow in Figure 18? Tested Concept

(OBQ08.240) A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding. Tested Concept

(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? Tested Concept

(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? Tested Concept

(OBQ04.167) A 44-year-old male has 7 months of left-sided radicular pain to his anteromedial shin and medial ankle which has failed non-operative treatment. He has no limitations to walking long distances and denies any pain in his right buttock or leg. Physical exam shows decreased strength to knee extension and decreased patellar reflexes on the left. A video of an MRI is shown in Video A. Operative treatment should include: Tested Concept