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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
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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 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
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 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 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 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. A sagittal and axial T2 MRI is shown in Figure A and B, respectively. 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 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
This video demonstrates how to measure and ankle-brachial index.
HPI - 75yo F w h/o L4-L5 L5-S1 laminectomy and discectomy several years ago without instrumented fusion presents complaining of severe axial lumbar pain of increasing intensity x 2 years despite physical therapy. She was seen by a Neurosurgeon who recommended no surgical intervention.
Non-operative vs operative?