Lumbar Spinal Stenosis

(OBQ18.188) A 72 year-old-female presents with low back pain and right hip pain that has progressively worsened over the last year. Her primary complaint is that she just can't walk the distance that she use to. Symptoms are worsened with prolonged walking and improve with sitting. The pain is located in her right buttock, right groin, and anterior thigh. Neurologic exam shows no motor deficits, normal sensation, and normal reflexes in the bilateral lower extremity. Physical examination of the spine shows a negative straight leg test, and increased pain in buttocks with prolonged erect standing. Physical exam of the right hip shows 0° of internal rotation and 10° of external rotation. Physical exam of the left hip shows 20° of internal rotation and 40° of external rotation. Range of motion testing of the right hip elicits pain. Current imaging is shown in Figures A & B. What would be the most appropriate step?

(SBQ18SP.29) A 56-year-old male has bilateral buttock pain worsened with walking and relieved when sitting down or leaning forward. His symptoms are severe enough that he is no longer playing golf and remaining active. He has a normal neurologic and vascular exam. He has MRI imaging performed represented in figures A-D. Figure E are his flexion and extension films. He has tried NSAIDs and physical therapy. Epidural injections in the past have provided him temporary relief only. What is the most appropriate next step in management?

(OBQ15.45) The cadaveric dissection in Figure A identifies anatomic structures that are at risk with both an anterior lumbar interbody fusion (ALIF) and trans-psoas lateral approaches. Which of the following clinical findings would be expected if the anatomic structure labelled Structure A in Figure A is injured?

(OBQ13.222) 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:

(OBQ13.190) 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?

(SBQ12SP.93) 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?

(SBQ12SP.31) 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?

(SBQ12SP.44) 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?

(SBQ12SP.53) 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?

(OBQ10.249) 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?

(OBQ09.148) 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?

(OBQ08.256) During lumbar decompression at L4/5, which of the following decompression techniques will destabilize the spine and require a L4/5 fusion.

(OBQ08.209) 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.

(OBQ07.94) 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?

(OBQ06.124) Patients with symptomatic spinal stenosis treated with surgical decompression compared to those treated nonoperatively have what clinical outcomes.

(OBQ05.167) 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?

(OBQ04.5) 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.