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Operative Techniques in Hand, Wrist, and Elbow Sur
Gain insights into operative techniques used in hand, wrist, and elbow surgeries. Learn about procedures and treatment options for conditions in these areas.
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Q: Figures 2a and 2b show the radiograph and MRI scan of a 56-year-old woman who has low back pain and right leg pain. She has grade 3/5 toe and ankle dorsiflexion strength on the right side. Nonsurgical management has failed to provide relief; therefore, surgery should include
A) L5 pars repair.
B) L5 laminectomy alone.
C) L5 laminectomy and fusion.
D) stand-alone anterior lumbar interbody fusion.
E) L5-S1 total disk replacement.
Correct answer: C
Explanation: The lateral radiograph and MRI scan demonstrate a grade 2 isthmic spondylolisthesis of L5 on S1. The radiograph shows a pars defect of L5. Isthmic spondylolistheses are most common at L5-S1. Degenerative spondylolistheses rarely progress beyond a grade 1 slip. The patient has frank neurologic weakness on the right side and nonsurgical management has failed to provide relief. In patients with significant motor weakness, neurologic decompression is indicated. An L5 pars repair is not recommended in patients with more than a grade 1 slip. Laminectomy alone can destabilize the spine and lead to further slippage and thus it is recommended to fuse the segment. A stand-alone anterior lumbar interbody fusion has a high failure rate with isthmic spondylolisthesis. Isthmic spondylolisthesis is a contraindication for lumbar total disk replacement. While there is some literature that supports fusion without laminectomy or decompression for patients with isthmic slips and radicular pain without neurologic deficit, this patient does not fulfill these criteria.
Q: Based on the current available best-evidence, what postoperative activities should be recommended for patients undergoing first-time lumbar diskectomy for disk herniation?
A) Bed rest
B) Avoid exercise for 6 to 8 weeks
C) Early return to low-intensity exercise
D) Early return to high-intensity exercise
E) Gradual return to low-intensity exercise after 6 weeks
Correct answer: D
Explanation: Recent evidence supports return to high-intensity exercise at 4 weeks for patients undergoing first-time lumbar diskectomy for disk herniation. Ostelo et al., in a Cochrane review update, demonstrated that exercise programs starting 4 to 6 weeks after surgery in patients undergoing first-time lumbar diskectomy for disk herniation lead to a faster decrease in pain and disability than no rehabilitation. Additionally, high-intensity exercise programs seem to lead to a faster decrease in pain and disability than low-intensity programs. Carragee et al., in a prospective review of 50 consecutive patients undergoing first-time lumbar diskectomy for disk herniation, demonstrated that lifting of postoperative activity restrictions after limited diskectomy allowed shortened sick leave without increased complications. He concluded that postoperative precautions in these patients may not be necessary.
Q: Figures 63a and 63b show the radiographs of a 38-year-old man who reports low back and bilateral lower extremity pain.
He has a history of a previous L5-S1 diskectomy. He has failed conservative management and is scheduled for surgery. What is the most likely diagnosis?
A) Recurrent disk herniation
B) Epidural fibrosis
C) Spondylolisthesis
D) Spinal stenosis
E) Arachnoiditis
Correct answer: A
Explanation: The radiographs show a loss of disk height at L5-S1 and a vacuum phenomenon. The MRI scan shows a large recurrent disk herniation at L5-S1 compressing the thecal sac and both S1 nerve roots. Recurrent disk herniation is the most common cause of persistent or recurrent symptoms after lumbar diskectomy. The incidence ranges from 5% to 15%. Epidural fibrosis is another possible cause of postoperative pain, but it usually manifests as radicular pain without neurologic deficit. Spondylolisthesis is a slippage of one vertebral body over another, which can cause spinal instability and nerve compression. Spinal stenosis is a narrowing of the spinal canal or neural foramina, which can cause neurogenic claudication and radiculopathy. Arachnoiditis is an inflammation of the arachnoid membrane, which can cause chronic pain, sensory loss, and bowel and bladder dysfunction.
