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The patient is presenting with a left paracentral L4-5 herniated disc compressing the traversing L5 nerve root, which would likely result in pain on the dorsum of the foot depicted by option D in figure C. Herniated nucleus pulposus is the pathologic displacement of disc material into the spinal canal and neuroforamina resulting in nerve compression and radicular pain. Patients will commonly complain of leg pain, and in some instances, motor weakness. L5 nerve root radiculopathy can classically lead to extensor hallicus longus weakness, but can also present with tibialis anterior weakness. The pain distribution in the leg depends on the affected nerve root. Correlation of radiographic and clinical findings is crucial prior to proceeding with surgical intervention to avoid unnecessary surgery. Millhouse et al. described the surgical technique for a microdiscectomy of a paracentral disc herniation. They recommended performing discectomies when patients have documented herniation on MRI imaging and lack improvement with 6 weeks of physical therapy or any neurologic deficits. They recommended addressing other compression causes including facet hypertrophy leading to lateral recess stenosis. Soliman et al. performed a retrospective study of 152 patients undergoing a limited microdiscectomy (fragmentectomy) of a herniated nucleus pulposus. They reported an 88.6% excellent-good longterm outcome with surgery, an 11.1% herniation recurrence rate, and a 5.6% progression to arthrodesis rate. The authors concluded that minimally invasive microdiscectomy with the removal of only the extruded/herniated fragment produces good clinical outcomes with relatively low progression to arthrodesis. Figures A and B are the sagittal and axial T2 MRI images of the lumbar spine depicting a left-sided paracentral disc herniation at the L4-5 level, compressing the traversing L5 nerve root. Figure C is the dermatome diagram of the lower extremity. Illustration A is a diagram of the lower extremity dermatomal distributions with the nerve root contributions detailed. Incorrect Answers: Answer 1: A corresponds to the L2 distribution. Answer 2: B corresponds to the L3 distribution. Answer 3: C corresponds to the L4 distribution. Answer 5: E corresponds to the S1 distribution.
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