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A surgical procedure is performed that involves removing the spinous process of L4, resecting the inferior 80% of the lamina on the right and the left of L4, and then removing the ligamentum flavum down to the superior lamina of L5. A bilateral medial faceteomy is performed that removed the medial 20% of the facet. The wound is then closed, and no instrumentation or fusion is performed. This procedure would be indicated in which of the following:
28-year old male with severe unilateral leg pain for 8 months that has failed nonoperative treatment. Imaging studies are shown in Figure A.
18-year old female with isolated low back pain that has failed to respond to 6 weeks of physical therapy. Imaging studies are shown in Figure B.
65-year old male with bilateral buttock pain, worse with walking and improves with sitting, that has failed epidural injections. Imaging studies are shown in Figure C.
22-year old male with isolated low back pain, that has failed non-operative management. Imaging studies are shown in Figure D.
31-year old male with bilateral buttock pain, worse with walking and improves with sitting, that has failed epidural injections. Imaging studies are shown in Figure E
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A 58-year-old man presents to the clinic with 9 months of progressive right lower extremity pain. Over the past 4 months, he also notes a decreased ability to walk long distances due to pain, which is relieved by sitting down. Figure A and B are his T2 sagittal and axial MRI scans, respectively. Which of the following statements is true regarding this patient's 4-year outcome in regards to surgical and non-surgical management?
Surgical management will lead to more improvement in pain but not function
Surgical management will have higher 4-year mortality
Surgical management will lead to more improvement in pain, function, and satisfaction
Nonsurgical management will lead to more improvement in pain but not function
Surgical management will lead more improvement in function, but less improvement in pain
A 52-year-old man presents to clinic with several months of worsening bilateral lower extremity pain and heaviness, especially when walking. His MRI is shown in Figures A and B. Which of the following statements is true regarding the anatomic structure that is contributing most to his pathology?
It inserts on the ventral surface of the L5 lamina closer to the inferior edge than the superior edge
It originates from the ventral surface of the L4 lamina closer to the superior edge than the inferior edge
It is the primary ligamentous restraint to thoracolumbar flexion in the Posterior Ligamentous Complex (PLC)
It is made primarily of type 2 collagen
It is one of the anatomic structures of the middle column
A 68-year-old male presents with symptoms of pain in the low back and bilateral buttocks. He denies significant pain radiating distal to his knee and denies any weakness or numbness in his legs. A video in Figure V shows axial and sagittal T2-weighted MRI images. Which of the following components of the history and physical would be most expected in this patient?
Decreased pain going down stairs
Increased pain with combined passive straight elevation of his right leg and dorsiflexion of his ankle
Progressive and step-wise worsening of symptoms
Improvement in pain while riding a stationary bicycle
Positive clonus and positive hoffman's sign.
Figure A is axial CT scan of the lumbar spine. The line from X to Y represents the AP canal diameter. The line from Z to W represents the right-to-left diameter of the canal. The circle represents cross-sectional area of the canal. Which of the following statements would define critical stenosis?
The distance from X to Y is less than 10mm
The distance from Z to W is less than 20mm
The area of the blue circle is 130mm2
The combined distance from X to Y and Z to W is less than 30mm
None of the above
A 69-year-old man presents to clinic with 9 months of worsening back and lower extremity pain that is worse with walking. Pain is improved by sitting down and leaning forward. He has attempted physical therapy without improvement in symptoms. A T2-weighted midline sagittal image is shown in Figure A. A T2-weighted axial image at the L4/5 disc space is shown in Figure B. A flexion and extension lateral radiograph are shown in Figure C and D. Performing a lumbar decompressive laminectomy alone at L4/5 will lead to which of the following?
Increased risk of adjacent segment degeneration requiring surgery
No improvement in symptoms compared to epidural steroid injection (ESI) at 4 years
Improvement in pain, function and disability compared to nonoperative treatment at 2 years but not 4 years
Improvement in pain, function and disability compared to nonoperative treatment at 2 and 4 years
No improvement in pain, function, and disability compared to nonoperative treatment at 2 and 4 years
A 45-year-old male underwent a lumbar discectomy 8 weeks ago. His surgery was remarkable for a dural tear that was repaired. He now presents with recurrence of his leg pain and back pain. Physical exam shows some mild erythema surrounding the incision. An MRI with and without gadolinium is performed and shown in Figure A and B. What is the most appropriate next step in management?
Continue routine postoperative care
Placement of a lumbar drain with a period of bedrest
Hospital admission, IV antibiotics, and serial ESR and CRP
CT guided aspiration
Surgical irrigation and debridement with commencement of antibiotics after cultures are obtained.
A 62-year-old man presents with 6 months of bilateral buttock and leg pain that is worse with prolonged standing and relieved with sitting. He denies symptoms with exercise on a stationary bike. Initial treatment including physical therapy, NSAIDS, and an epidural steroid injection provided only temporary relief of his symptoms, which have returned and are now severe. On physical exam he has normal motor strength in his lower extremities, negative straight-leg raise tests bilaterally, and palpable bilateral dorsalis pedis pulses. Lumbar flexion-extension radiographs show no spondylolisthesis or instability. An axial T2 MRI cut is shown in figure A. What is the most appropriate next step in management?
A decompressive laminectomy with bilateral medial facetectomies and foraminotomies
A decompressive laminectomy, bilateral medial facetectomies and foraminotomies, and an instrumented fusion
A left sided microdiskectomy
Continues physical therapy
Referral to vascular surgery for evaluation for peripheral vascular disease
A 68-year-old man presents with bilateral buttock and leg pain, worse on the right. His pain is worse with prolonged standing and improves with sitting. His symptoms have progressed to the point that it is now difficult for him to walk to the mailbox. His physical exam is remarkable for 4/5 weakness to ankle dorsiflexion on the right. Four months of physical therapy and a series of epidural corticosteroid injections failed to improve his symptoms. Figure A and B are an AP and lateral lumbar spine radiograph. Figures C and D are flexion/extension radiographs. Figure E is a sagittal MRI, and Figure F is an axial MRI through L4/5. The axial images through L3/4 and L5/S1 do not demonstrate any signs of significant nerve root compression. What is the most appropriate next step in treatment?
Continued physical therapy
L4/5 microdiskectomy with a midline approach
L4/5 microdiskectomy with a Wiltse far lateral approach
L4/5 laminectomy, bilateral lateral recess decompression and foraminotomies
L4/5 laminectomy, bilateral lateral recess decompression and foraminotomies, and instrumented fusion
During lumbar decompression at L4/5, which of the following decompression techniques will destabilize the spine and require a L4/5 fusion.
Removal of > 50% of the L4/5 nucleus pulpusus
Removal of the L4 and L5 spinous process and interspinous ligament
A medial facetectomy removing 20% of the right L4/5 facet joint
Bilateral resection of the L4 inferior articular process
A unilateral hemilaminectomy
A 62-year-old female has a decompressive laminectomy for spinal stenosis and symptoms of right leg pain. Preoperative flexion and extension radiographs of the lumbar spine are shown in Figure A. A preoperative sagittal MRI is shown in Figure B. Following surgery she reports no significant improvement in her right leg pain. What is the most likely cause of her residual leg pain.
Recurrent disk herniation
Residual foraminal stenosis
Cauda equina syndrome
A dural tear occurs during a routine lumbar laminectomy for spinal stenosis. A water-tight repair is subsequently performed. How will this affect postoperative care and ultimate clinical outcomes?
there is an increased risk of wound infection
the patient must remain flat in bed for seven days
the clinical outcome will not be affected
the patient will have a worse clinical outcome
the patient should remain on PO antibiotics for ten days following surgery
Patients with symptomatic spinal stenosis treated with surgical decompression compared to those treated nonoperatively have what clinical outcomes.
Worse clinical outcomes at four years
No difference in clinical outcomes at four years
Improved clinical outcomes in pain only at four years
Improved clinical outcomes in function only at four years
Improved clinical outcomes in pain and function at four years
A 32-year-old man underwent a lumbar microdiskectomy and an incidental dural tear occurred. A hemilaminectomy was performed to obtain adequate visualization of the defect, and primary repair of the tear was performed. One month postoperatively he returns to the office complaining of severe headaches and occasional nausea which is worse with standing. He denies fever or chills. On physical exam his wound is well healed with no cellulitis or erythema. WBC and ESR are within normal limits. What is the most likely diagnosis?
Cerebrospinal fluid leak
A 71-year-old female is admitted to the hospital for severe bilateral buttock and leg pain with ambulation that has failed to improve with nonoperative management. An MRI is shown in Figure A. You plan on proceeding with lumbar decompression. What is the most powerful preoperative prognostic factor for clinical outcomes with surgical treatment of this condition.
Anterior compression due to disc herniation
Comorbid medical conditions
Average household income