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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?
Continued rest, formal physical therapy and anti-inflammatory medications
Targeted chemonucleolysis of the L4-5 disc
Discectomy and interbody fusion L4-5
Discectomy utilizing a midline approach between the spinous process and multifidus
Discectomy utilizing an intermuscular approach between multifidus and longissimus
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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?
Continued oral anti-inflammatories
Right L4/5 microdiscectomy
Right L4/5 minimally invasive transforaminal interbody fusion
Referral for EMG and nerve conduction studies
L4/5 posterior decompression and instrumented fusion
A 56-year-old man presents with 6 weeks of worsening back and left sided lower extremity pain and weakness. He has severe pain that radiates from the back to the groin and anteromedial thigh. His axial MRI image is shown in Figure 1. Which of the following physical examination findings would be most consistent with his imaging?
Decreased sensation on the lateral aspect of the foot
Weakness of quadriceps
Weakness of hip adduction
Weakness of extensor hallucis longus
Normal physical examination at rest, but leg heaviness after ambulation
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?
Medical management with GABA analogs
Disectomy and instrumented fusion
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?
Equal limb pain and equal functional outcomes
Improved limb pain and improved functional outcomes
Worsened limb pain and worsened functional outcomes
Worsened limb pain but improved functional outcomes
Improved limb pain but worsened functional outcomes
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?
Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35
Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35
Age > 41 years, divorced, presence of worker compensation claim
Age < 31 years, absence of joint problems, no workers compensation
Age > 41 years, absence of joint problems, married status
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?
Left L2-3 foraminal herniated nucleus pulposis
Left L4-5 central herniated nucleus pulposis
Left L4-5 paracentral herniated nucleus pulposis
Left L4-5 foraminal herniated nucleus pulposis
Left L5-S1 paracentral herniated nucleus pulposis
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?
L4/5 microdiskectomy through midline approach
L4/5 microdiskectomy with far lateral Wiltse approach
L4/5 Decompression, TLIF, and instrumented fusion
L4/5 Decompression, PLIF, and instrumented fusion
L4/5 Anterior Lumbar Interbody Fusion
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?
Equivalent relief from symptoms and equivalent improvement in quality of life
Less relief from symptoms and less improvement in quality of life
Improved relief from symptoms and greater improvement in quality of life
Significantly decreased return to work status
Significantly improved return to work status
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
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?
Refer the patient to pain management
Repeat epidural steroid injection
Laminotomy and diskectomy
Spinal fusion with interbody cage and posterior instrumentation
What structure is located at the tip of the arrow in Figure 18?
Left L3 nerve root
Right L3 nerve root
Right L4 segmental artery
Right L4 nerve root
Left lateral disk herniation
A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding.
Weakness to hip flexion, numbness on the inner thigh, a decreased patellar reflex
Weakness to knee extension, numbness on the anterior shin, a decreased patellar reflex
Weakness to ankle dorsal flexion, numbness on the dorsal foot, a decreased Achilles reflex
Weakness to extensor hallicus longus, numbness in the first web space, a decreased Achilles reflex
Weakness to ankle plantar flexion, numbness on the lateral foot, normal reflexes
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?
Worse outcomes in pain, physical function, and return to work status at 4 years.
Equivalent outcome in pain and physical function at 4 years.
Improved outcome in pain and physical function at 4 years.
Improved outcome in return to work status only at 4 years.
Worse outcome in return to work status with equivalence in pain and physical function at 4 years.
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?
Posterior spinal fusion with instrumentation
Anti-inflammatory medication and physical therapy
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:
anterior retroperitoneal approach with anterior lumbar interbody fusion (ALIF)
anterior transperitoneal approach with discectomy only
posterior midline lumbar laminectomy, decompression and fusion with pedicle screw fixation
posterior midline hemilaminectomy with discectomy
discectomy from extra-foraminal approach with a lateral paraspinal muscle-splitting approach