Introduction Epidemiology 95% involve L4/5 or L5/S1 levels L5/S1 most common level peak incidence is 4th and 5th decades only ~5% become symptomatic 3:1 male:female ratio Pathoanatomy recurrent torsional strain leads to tears of outer annulus which leads to herniation of nucleus pulposis Prognosis 90% of patients will have improvement of symptoms within 3 months with nonoperative care. size of herniation decreases over time (reabsorbed) sequestered disc herniations show the greatest degree of spontaneous reabsorption macrophage phagocytosis is mechanism of reabsorption Anatomy Complete intervertebral disc anatomy and biomechanics Disc composition annulus fibrosis composed of type I collagen, water, and proteoglycans 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 polysacharide content and high water content (88%) 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 axillary can affect both exiting and descending nerve roots Anatomic 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 Presentation Symptoms can present with symptoms of axial back pain (low back pain) this may be discogenic or mechanical in nature radicular pain (buttock and leg pain) often worse with sitting, improves with standing symptoms worsened by coughing, valsalva, sneezing cauda equina syndrome (present in 1-10%) bilateral leg pain LE weakness saddle anesthesia bowel/bladder symptoms Physical exam see lower extremity neuro exam motor exam & reflexes L3 radiculopathy hip adduction weakness L4 radiculopathy knee extension weakness (L4 > L3 contribution) decreased patellar reflex L5 radiculopathy ankle dorsiflexion weakness (L5 > L4 contribution) test by having patient walk on heels EHL weakness (L5) manual testing hip abduction weakness (L5) have patient lie on side on exam table and abduct leg against resistance S1 radiculopathy ankle plantar flexion weakness (S1) have patient do 10 single leg toes stands decreased Achilles tendon reflex provocative tests straight leg raise a tension sign for 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 Lesegue sign SLR aggravated by forced ankle dorsiflexion 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 may show loss of lordosis (spasm) loss of disc height lumbar spondylosis (degenerative changes) MRI without gadolinium modality of choice for diagnosis of lumbar and cervical 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 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) MRI with gadolinium useful for revision surgery 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, and antiinflammatory medications indications first line of treatment for most patients with disc herniation 90% improve without surgery technique bedrest followed by progressive activity as tolerated medications NSAIDS muscle relaxants (more effective than placebo but have side effects) oral steroid taper physical therapy extension exercises extremely beneficial traction chiropractic manipulation selective nerve root corticosteroid injections indications second line of treatment if therapy and medications fail technique epidural selective nerve block 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 Operative laminotomy and discectomy (microdiscectomy) indications persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections) progressive and significant weakness cauda equina syndrome technique can be done with small incision or through "tube" access 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 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 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 far lateral microdiskectomy indications for far-lateral disc herniations technique utilizes a paraspinal approach of Wiltse Complications of Surgery Dural tear (1%) if have tear at time of surgery then perform water-tight repair Recurrent HNP can treat nonoperatively initially outcomes for revision discectomy have been shown to be as good as for primary discectomy Discitis (1%) Vascular catastrophe caused by breaking through anterior annulus and injuring vena cava/aorta
Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Microdiscectomy Orthobullets Team Spine - Lumbar Disc Herniation
QUESTIONS 1 of 42 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 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 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 (OBQ09.235) 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 Review Topic QID: 3048 FIGURES: A B C D E 1 Figure A 8% (159/2099) 2 Figure B 11% (231/2099) 3 Figure C 35% (744/2099) 4 Figure D 15% (317/2099) 5 Figure E 30% (640/2099) ML 5 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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 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 (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. Leg pain and paresthesias are localized to his buttock, lateral and posterior calf, and the dorsal aspect of his foot. On strength testing, he is graded a 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis. Sagittal and axial T2-weighted MRI images are shown in Figure A and B. Which of the following treatment modalities will allow the greatest improvement of physical functioning? Review Topic QID: 4590 FIGURES: A B 1 Observation alone 1% (35/2747) 2 Physical therapy 2% (66/2747) 3 Medical management with GABA analogs 1% (24/2747) 4 Discectomy 84% (2312/2747) 5 Disectomy and instrumented fusion 10% (282/2747) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 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? Review Topic QID: 3706 FIGURES: A 1 Equal limb pain and equal functional outcomes 57% (2563/4461) 2 Improved limb pain and improved functional outcomes 11% (489/4461) 3 Worsened limb pain and worsened functional outcomes 15% (655/4461) 4 Worsened limb pain but improved functional outcomes 1% (57/4461) 5 Improved limb pain but worsened functional outcomes 15% (671/4461) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ08.240) A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding. Review Topic QID: 626 1 Weakness to hip flexion, numbness on the inner thigh, a decreased patellar reflex 3% (35/1098) 2 Weakness to knee extension, numbness on the anterior shin, a decreased patellar reflex 74% (817/1098) 3 Weakness to ankle dorsal flexion, numbness on the dorsal foot, a decreased Achilles reflex 16% (171/1098) 4 Weakness to extensor hallicus longus, numbness in the first web space, a decreased Achilles reflex 5% (52/1098) 5 Weakness to ankle plantar flexion, numbness on the lateral foot, normal reflexes 1% (14/1098) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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? Review Topic QID: 3106 1 Equivalent relief from symptoms and equivalent improvement in quality of life 2% (45/1904) 2 Less relief from symptoms and less improvement in quality of life 69% (1315/1904) 3 Improved relief from symptoms and greater improvement in quality of life 1% (22/1904) 4 Significantly decreased return to work status 26% (504/1904) 5 Significantly improved return to work status 1% (12/1904) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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? Review Topic QID: 3019 FIGURES: A B 1 Refer the patient to pain management 1% (11/2173) 2 Repeat epidural steroid injection 1% (13/2173) 3 Transforaminal diskectomy 6% (133/2173) 4 Laminotomy and diskectomy 90% (1946/2173) 5 Spinal fusion with interbody cage and posterior instrumentation 3% (60/2173) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 154 FIGURES: A 1 Microdiskectomy 6% (135/2184) 2 Posterior spinal fusion with instrumentation 1% (11/2184) 3 Decompression only 2% (44/2184) 4 Strict bedrest 1% (15/2184) 5 Anti-inflammatory medication and physical therapy 90% (1962/2184) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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? Review Topic QID: 4462 1 Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35 7% (277/3842) 2 Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35 19% (718/3842) 3 Age > 41 years, divorced, presence of worker compensation claim 1% (35/3842) 4 Age < 31 years, absence of joint problems, no workers compensation 37% (1419/3842) 5 Age > 41 years, absence of joint problems, married status 35% (1360/3842) ML 5 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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? Review Topic QID: 3659 1 Left L2-3 foraminal herniated nucleus pulposis 9% (264/3099) 2 Left L4-5 central herniated nucleus pulposis 3% (100/3099) 3 Left L4-5 paracentral herniated nucleus pulposis 10% (325/3099) 4 Left L4-5 foraminal herniated nucleus pulposis 76% (2353/3099) 5 Left L5-S1 paracentral herniated nucleus pulposis 1% (35/3099) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 544 1 Worse outcomes in pain, physical function, and return to work status at 4 years. 3% (39/1194) 2 Equivalent outcome in pain and physical function at 4 years. 43% (510/1194) 3 Improved outcome in pain and physical function at 4 years. 47% (564/1194) 4 Improved outcome in return to work status only at 4 years. 2% (18/1194) 5 Worse outcome in return to work status with equivalence in pain and physical function at 4 years. 5% (57/1194) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 3488 FIGURES: A B 1 L4/5 microdiskectomy through midline approach 72% (1866/2585) 2 L4/5 microdiskectomy with far lateral Wiltse approach 7% (179/2585) 3 L4/5 Decompression, TLIF, and instrumented fusion 6% (165/2585) 4 L4/5 Decompression, PLIF, and instrumented fusion 12% (323/2585) 5 L4/5 Anterior Lumbar Interbody Fusion 1% (35/2585) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 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
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Recurrent Lumbar Disc Herniation (C2596) Spine - Lumbar Disc Herniation HPI - 69 ys old female patient ..complaining of LBP with rt sciatica Based on the MRI shown, what do you think is the lesion seen in the right paracentral space with displacement of the thecal sac. 6/1/2016 702 14 6 Case of failed back surgery (C1797) Spine - Lumbar Disc Herniation HPI - Patient is 32-year old orthopedic surgeon with history of right side S1 radiculopathy for 8 months that progressed to bilateral S1 radiclopathy for last 3 months. Epidural steroid injection after 1st 2 month did not lead to improvement in sign and symptom. No complaints of muscle weakness and no bladder or bowel involvement. Paraesthesia improved after first 3 month. Pain last 2 month increase , interfere significantly with daily activity Lumbar discectomy performed in 4 / 12 / 2013. Fenestration done and sequestrectomy done . Surgeon how did the surgery tell me he found all disc sequestrated annulus healed no any further compression on root . Bleeding from epidural vein occur , gel foam Postop. No any improvement ,still bilateral S1 radiculopathy more sever in right side with intermitten throbbing pain in right paraspinal area at level of sacral ala at rest With Backache The pain even more intense than preoperative p what your opnion about the case 2/24/2014 244 4 18 Lumbar disc prolapse (C1480) Spine - Lumbar Disc Herniation HPI - The patient presents with 6 week hx of rt side leg pain and paraesthesia below knee in the S1 dermatome. He has a mild backache, no fever, no weakness. Pain intensity changes with position. It is mild in the morning and increases gradually. It is worse with sitting more than 30 minutes. Current management with NSAISs and physical therapy. What would be your next step in management for this patient? 4/18/2013 292 7 17 See More See Less