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 ankle inversion weakness 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 professional athletes younger age, greater number of games played prior to injury 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 has not been shown to adversely affect long term outcomes Recurrent HNP can treat nonoperatively initially revision rate a 8-year-follow-up is 15% according to SPORT trial outcomes for revision discectomy have been shown to be as good as for primary discectomy Discitis (1%) 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. Vascular catastrophe caused by breaking through anterior annulus and injuring vena cava/aorta
Technique Guide 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 47 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 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 (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? Review Topic | Tested Concept QID: 4662 FIGURES: A B Type & Select Correct Answer 1 Continued rest, formal physical therapy and anti-inflammatory medications 5% (206/4013) 2 Targeted chemonucleolysis of the L4-5 disc 1% (28/4013) 3 Discectomy and interbody fusion L4-5 6% (231/4013) 4 Discectomy utilizing a midline approach between the spinous process and multifidus 73% (2927/4013) 5 Discectomy utilizing an intermuscular approach between multifidus and longissimus 15% (598/4013) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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? Review Topic | Tested Concept QID: 4906 FIGURES: A B Type & Select Correct Answer 1 Continued oral anti-inflammatories 3% (67/2507) 2 Right L4/5 microdiscectomy 92% (2302/2507) 3 Right L4/5 minimally invasive transforaminal interbody fusion 1% (27/2507) 4 Referral for EMG and nerve conduction studies 1% (18/2507) 5 L4/5 posterior decompression and instrumented fusion 3% (79/2507) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept 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 | Tested Concept QID: 4590 FIGURES: A B Type & Select Correct Answer 1 Observation alone 1% (36/3108) 2 Physical therapy 2% (75/3108) 3 Medical management with GABA analogs 1% (29/3108) 4 Discectomy 84% (2612/3108) 5 Disectomy and instrumented fusion 10% (325/3108) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review 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? Review Topic | Tested Concept QID: 3706 FIGURES: A Type & Select Correct Answer 1 Equal limb pain and equal functional outcomes 56% (2791/4945) 2 Improved limb pain and improved functional outcomes 11% (546/4945) 3 Worsened limb pain and worsened functional outcomes 15% (732/4945) 4 Worsened limb pain but improved functional outcomes 1% (67/4945) 5 Improved limb pain but worsened functional outcomes 16% (781/4945) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review 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? Review Topic | Tested Concept QID: 4462 Type & Select Correct Answer 1 Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35 7% (308/4200) 2 Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35 18% (771/4200) 3 Age > 41 years, divorced, presence of worker compensation claim 1% (44/4200) 4 Age < 31 years, absence of joint problems, no workers compensation 37% (1537/4200) 5 Age > 41 years, absence of joint problems, married status 36% (1504/4200) L 5 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept 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? Review Topic | Tested Concept QID: 3659 Type & Select Correct Answer 1 Left L2-3 foraminal herniated nucleus pulposis 8% (293/3500) 2 Left L4-5 central herniated nucleus pulposis 3% (111/3500) 3 Left L4-5 paracentral herniated nucleus pulposis 10% (361/3500) 4 Left L4-5 foraminal herniated nucleus pulposis 76% (2666/3500) 5 Left L5-S1 paracentral herniated nucleus pulposis 1% (46/3500) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review 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? Review Topic | Tested Concept QID: 3488 FIGURES: A B Type & Select Correct Answer 1 L4/5 microdiskectomy through midline approach 72% (2215/3091) 2 L4/5 microdiskectomy with far lateral Wiltse approach 7% (217/3091) 3 L4/5 Decompression, TLIF, and instrumented fusion 7% (204/3091) 4 L4/5 Decompression, PLIF, and instrumented fusion 13% (391/3091) 5 L4/5 Anterior Lumbar Interbody Fusion 1% (42/3091) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review 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? Review Topic | Tested Concept QID: 3106 Type & Select Correct Answer 1 Equivalent relief from symptoms and equivalent improvement in quality of life 2% (52/2198) 2 Less relief from symptoms and less improvement in quality of life 69% (1506/2198) 3 Improved relief from symptoms and greater improvement in quality of life 1% (29/2198) 4 Significantly decreased return to work status 27% (583/2198) 5 Significantly improved return to work status 1% (19/2198) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept 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 | Tested Concept QID: 3048 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 8% (205/2512) 2 Figure B 11% (272/2512) 3 Figure C 31% (769/2512) 4 Figure D 16% (414/2512) 5 Figure E 34% (843/2512) L 5 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review 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? Review Topic | Tested Concept QID: 3019 FIGURES: A B Type & Select Correct Answer 1 Refer the patient to pain management 0% (10/2537) 2 Repeat epidural steroid injection 1% (16/2537) 3 Transforaminal diskectomy 7% (184/2537) 4 Laminotomy and diskectomy 88% (2242/2537) 5 Spinal fusion with interbody cage and posterior instrumentation 3% (72/2537) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK 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? Review Topic | Tested Concept QID: 6191 FIGURES: A Type & Select Correct Answer 1 Left L3 nerve root 3% (14/401) 2 Right L3 nerve root 78% (313/401) 3 Right L4 segmental artery 7% (30/401) 4 Right L4 nerve root 9% (38/401) 5 Left lateral disk herniation 0% (2/401) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.240) A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding. Review Topic | Tested Concept QID: 626 Type & Select Correct Answer 1 Weakness to hip flexion, numbness on the inner thigh, a decreased patellar reflex 3% (41/1545) 2 Weakness to knee extension, numbness on the anterior shin, a decreased patellar reflex 74% (1136/1545) 3 Weakness to ankle dorsal flexion, numbness on the dorsal foot, a decreased Achilles reflex 16% (250/1545) 4 Weakness to extensor hallicus longus, numbness in the first web space, a decreased Achilles reflex 5% (82/1545) 5 Weakness to ankle plantar flexion, numbness on the lateral foot, normal reflexes 1% (23/1545) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review 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? Review Topic | Tested Concept QID: 544 Type & Select Correct Answer 1 Worse outcomes in pain, physical function, and return to work status at 4 years. 3% (51/1593) 2 Equivalent outcome in pain and physical function at 4 years. 41% (649/1593) 3 Improved outcome in pain and physical function at 4 years. 49% (785/1593) 4 Improved outcome in return to work status only at 4 years. 1% (20/1593) 5 Worse outcome in return to work status with equivalence in pain and physical function at 4 years. 5% (78/1593) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review 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? Review Topic | Tested Concept QID: 154 FIGURES: A Type & Select Correct Answer 1 Microdiskectomy 7% (176/2582) 2 Posterior spinal fusion with instrumentation 1% (13/2582) 3 Decompression only 2% (55/2582) 4 Strict bedrest 1% (20/2582) 5 Anti-inflammatory medication and physical therapy 89% (2299/2582) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review 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: Review Topic | Tested Concept QID: 1272 FIGURES: V Type & Select Correct Answer 1 anterior retroperitoneal approach with anterior lumbar interbody fusion (ALIF) 6% (258/4005) 2 anterior transperitoneal approach with discectomy only 1% (34/4005) 3 posterior midline lumbar laminectomy, decompression and fusion with pedicle screw fixation 27% (1084/4005) 4 posterior midline hemilaminectomy with discectomy 29% (1147/4005) 5 discectomy from extra-foraminal approach with a lateral paraspinal muscle-splitting approach 36% (1447/4005) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept
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