What is the optimal next step? An 11-year-old male complains of one year duration of neck pain. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 10a. In patients with a symptomatic lumbar disc herniation who have failed nonoperative management, which of the following patient characteristics are associated with improved treatment effects with surgery? The physical exam is significant for 15 degrees of internal rotation with the hip in 90 degrees of flexion and a positive flexion-internal rotation impingement sign. Slightly flex the hip (relaxes quadriceps tension). Osteochondroma & Multiple Hereditary Exostosis. Treatment is observation for genu valgum <15 degrees in a child <7 years of age. Hyperextension of the femoral component. He denies any acute traumatic injuries. SI Dislocation & Crescent FX Medial parapatellar arthrotomy avoiding the patellar tendon. Which of the following treatment options is most appropriate? A 15-year-old boy presents with a painful mass over his great toe. Excessive internal rotation of the tibial component. Diagnosis can be suspected clinically with presence of a traumatic knee effusion with increased laxity on Lachman's test but requires MRI studies to confirm diagnosis. Given this patient's presentation and family history, you initially recommend molecular genetic testing. WebPatellar resurfacing (PR) and peripheral patellar denervation (PD) are common surgical treatments for knee osteoarthritis (KOA) in total knee arthroplasty (TKA). 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Alternative Bearing Surfaces in Total Hip Replacement, THA - Direct Anterior Approach Total Hip Replacement, Basic Skills Total Hip Arthroplasty: Part 1 Approach and Dislocation. While his back pain has improved slightly, his leg pain remain severe and interferes with his ability to sleep and work. THA Dislocation THA Sciatic Nerve Palsy THA Leg Length Discrepancy THA Vascular Injury & Bleeding THA Chronic Complications THA Aseptic Loosening THA Iliopsoas Impingement TKA Patellar Prosthesis Loosening Counseling for the patient would include telling the patient that he is more likely to have all of the following compared to a patient carrying the EXT 2 gene mutation EXCEPT: Lower functional knee and elbow range of motion, Higher rate of pelvic and flatbone involvement. A standing alignment radiograph is shown in Figure B with the mechanical lateral distal femoral angle measured at 73 (mLDFA 88, range 85-90), an mechanical medial proximal tibial angle of 87 (mMPTA 87, range 85-90), and a tibial femoral angle of 25(range 5-10). Which of the following clinical scenarios would best produce this pattern of symptoms? joint pain. The pelvic ring formed from 2 innominate bones, articulate posteriorly with the sacrum and anteriorly through pubis symphysis, Each innominate bone is composed of three fused bones: ilium, ischium, and pubis, iliopectineal eminence - region union between ilium and pubis, the anterior portion of the gluteus medius insertion and thickening of the iliac crest, important fixation pathway for fractures of the pelvis, transverse process of L4/L5 to posterior ilium, a fibrocartilaginous disc between innominate bones, bifurcates at L4 into common iliac system, continues as the common femoral artery (distal to the inguinal ligament), divides distal and posterior near the SI joint into, leads to the iliolumbar artery, lateral sacral artery, and terminates as the superior gluteal artery, leads to the obturator artery and inferior gluteal artery, terminating as the internal pudendal artery, vascular anastomosis that connects the external iliac artery (or inferior epigastric artery) and obturator artery, encountered during anterior approaches to pelvis (ilioinguinal and modified Stoppa), can result in brisk bleeding with rapid blood loss if not identified and ligated, injury in pelvic fractures can account for majority of blood loss, standard radiograph for all trauma patients, cranial tilt (x-ray tube angle toward head and photons beamed in a caudal direction), caudal tilt (x-ray tube angled toward feet and beamed in cranial direction), demonstrates cranial-caudal displacement of the pelvic ring and sacral morphology, pseudo-lateral (oblique) views of the pelvis designed to evaluate the columns and walls of the acetabulum, the views are reciprocal, meaning a LEFT iliac-oblique is the same as a RIGHT obturator-oblique, assessment of the ilioischial line of the posterior column, the roof of the acetabulum, the anterior acetabular wall, andIliac crest. The quadriceps is a group of muscles on the front of the thigh which straighten the knee. Physical exam and radiographic evaluation demonstrate femoroacetabular impingement with an associated labral tear. Copyright 2022 Lineage Medical, Inc. All rights reserved. Proximal Tib-Fib Dislocation Knee Overuse injuries Patellar Tendinitis Patellar Tendon Rupture Orthobullets Team Knee & Sports - Snapping Hip (Coxa Saltans) Listen Now 14:22 min. Radiographs are shown in figure A. A 12-year-old girl with a several-year history of multiple bony protuberances presents to your clinic for evaluation. Combined radius and ulna corrective osteotomy. Physical exam shows normal strength in all four extremities and hyper-reflexic patellar tendons. Copyright 2022 Lineage Medical, Inc. All rights reserved. (SBQ12SP.99) A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. 6/4/2020. Mutations in the tumor suppressor genes EXT1 and EXT2 gene leads to a condition characterized by which of the following images. Continued rest, formal physical therapy and anti-inflammatory medications, Targeted chemonucleolysis of the L4-5 disc, Discectomy utilizing a midline approach between the spinous process and multifidus, Discectomy utilizing an intermuscular approach between multifidus and longissimus. Arthroplasty Preoperative Medical Optimization, Idiopathic Transient Osteoporosis of the Hip (ITOH), THA Pseudotumor (Metal on Metal Reactions), TKA Postoperative Rehabilitation & Outpatient Management. In humans, the patella is the largest sesamoid bone (i.e., embedded within a tendon may affect quadriceps strength. He requires a shoe lift to ambulate. disadvantages. (SAE07HK.34) Multiple hereditary exostosis, chondrosarcoma, Multiple hereditary exostosis, enchondroma, Multiple enchondromatosis, chondroblastoma, Multiple hereditary exostosis, osteosarcoma. WebPatellar Dislocation and Instability in Children (Unstable Kneecap) Your child's kneecap (patella) is usually right where it should beresting in a groove at the end of the thighbone (femur). He is cleared by the trauma team, and undergoes early total care with reamed femoral and tibial nailing. both anterior and posterior) cruciate ligament tears with either medial collateral ligament tear or posterolateral corner injury 4. Surgical management is indicated for severe and progressive genu valum in a child > 7 years of age. Sagittal and axial MRI images are shown in Figure A and B. On physical exam, he is unable to go from a sitting position to a standing position with a single leg on the left, whereas he has no difficulty on the right. years, rapidly progressive deformity after age of 7, rate of correction with hemiepiphysiodesis is variable, angular correction of 7 degrees per year at the distal femur, angular correction of 5 degrees per year at the proximal tibia, > 15-20 of valgus in a patient between ages 7-10, if line drawn from center of femoral head to center of ankle falls in lateral quadrant of tibial plateau in patient > 10 yrs of age, location of hemiepiphysiodesis dependent on 3 factors, place extraperiosteally to avoid physeal injury, implant placed midsagittal to avoid sagittal plane deformity, one eight-plate or two staples per physis is generally sufficient, follow patients often to avoid varus overcorrection, remove once mechanical axis passes through center or knee or slightly medial, account for rebound medial overgrowth resulting in loss of correction, growth begins within 24 months after removal of the tether, insufficient remaining growth to correct deformity with hemiepiphysiodesis, non-functional growth plate (ie presence of bar, infection etc), lateral distal femur opening wedge osteotomy, angular correction can be adjusted to desired correction, prolonged immobilization to allow graft to heal, medial distal femur closing wedge osteotomy, avoid distracting lateral common peroneal nerve, technically demanding to remove precise angular wedge, perform a peroneal nerve decompression at the time of surgery prior to distraction, intermuscular septum separating the anterior and lateral compartments, gradual correction of severe deformities can be done with circular external fixator, insufficient physeal growth or encroaching maturity, defined as a loss of 5 degrees of correction once the plate is removed, younger age at plate application and removal, intentional overcorrection increased risk, consider slight overcorrection prior to implant removal, may not prevent rebound growth but may limit recurrence of deformity, consider performing growth modulation closer to skeletal maturity for milder deformities, remove implant with 2-3 years after insertion, Idiopathic genu valgum has a better prognosis than pathological etiology with hemiepiphysiodesis, Physiologic genu valgum resolves spontaneous in vast majority by age of 7, Deformity after a proximal metaphyseal tibia fracture (Cozen) should be observed as most remodel, maximum magnitude of deformity reached approximately 12-18 mo after injury, Threshold of deformity that leads to future degenerative changes is unknown, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Treatment for Cauda Equina Syndrome in contrast is emergent microdiscectomy within 48 hours. Fractures of the distal femur or proximal tibia are also common (~15%) 2,4 . He reports no night pain or constitutional symptoms. (OBQ05.180) On examination, she has palpable masses about the bilateral knees, wrists, and shoulders. 4/20/2020. (OBQ10.18) Improved outcome in return to work status only at 4 years. 10/19/2019. Genu Valgum is a normal physiologic process in children which may also be pathologic if associated with skeletal dysplasia, physeal injury, tumors or rickets. A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. What intra-operative technique could have prevented this complication? Flexion and extension radiographs show no evidence of spondylolisthesis. Team Orthobullets (J) Trauma - Proximal Third Tibia Fracture; Listen Now 19:10 min. Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35, Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35, Age > 41 years, divorced, presence of worker compensation claim, Age < 31 years, absence of joint problems, no workers compensation, Age > 41 years, absence of joint problems, married status. exacerbating activitis include hip flexion or external rotation in weight bearing stance, lateral hip pain and a limp or Trendelenburg gait may occur with abductor fatigue, evaluation of gait; abductor fatigue or Trendelnburg sign, overall ligamentous laxity; Beighton score, increased internal rotation with the hip in flexion, lateral decubitus position, hip placed in extension as examiner applies progressive external rotation and adduction, anterior-directed force on the posterior greater trochanter, lateral center-edge angle (LCEA) of Wiberg, assesses superolateral coverage of the femoral head on the AP view, angle between a verticle line through the center of the femoral head and the acetabular edge, inclination of the weight bearing portion of the acetabulum, angle formed between the horizontal and a line along the superior acetabulum, assesses anterior coverage of the femoral head, angle created between a vertical line through the center of the femoral head and the anterior acetabulum, >40 indicative of femoroacetabular impingement (FAI), Femoro-Epiphyseal Acetabular Roof (FEAR) index, angle formed between the horizontal portion of the central proximal femoral physeal scar and the acetabular index, FEAR index <5 indicative of a stable hip not requiring treatment, should only be ordered by treating surgeon, adequate assessment of acetabular and proximal femoral osseous morphology including excessive anteversion or retroversion, distal femur should be included in patients with clinical signs of femoral anteversion, diameter of femoral canal may be over-estimated on AP radiographs and underestimated on lateral radiographs due to rotational mismatch of the metaphysis and diaphysis, Identification and prevention of infantile developmental dysplasia (DDH), Pavlik harness, closed and open reductions, spica casting, proximal femoral osteotomies, role of long-term nonsurgical management in symptomatic dysplasia is limited given premature progression of secondary OA, adjunct procedure to PAO for enhanced visualization and management of chondral, labral and proximal femoral cam-type lesions, contraindicated in the setting of moderate to severe dysplasia, chondral and labral pathology is a sequelae of osseous instability and may recur or progress if underlying pathology is not corrected, associated with accelerated progression of arthritis, hip subluxation, less functional improvement, as well as increased risk of surgical failure and reoperation, intraoperative dynamic testing of hip motion is needed to determine the need for femoral osteotomy, minimum of 90 flexion and 15 internal rotation to prevent FAI, preserved integrity of the posterior column, which allows patients to weight bear as tolerated postoperatively, reliably improves radiographic parameters and symptomatology, 92% survivorship at 15 years in avoiding THA, recommended for patients with inadequate femoral head coverage and, 84% survivorship at 17 years with advanced OA as an endpoint, advanced DDH and asphericity of the femoral head associated with poor outcomes, can be used for Crowe type I or II disease, higher revision and complication rate with hip resufracing in patients with DDH compared to general population, treatment of choice for patients with end-stage OA secondary to dysplasia, outcomes for Crowe I and II patients are in similar to those of THA for primary OA in the short term, revision rates for Crowe III and IV are higher than non-dysplastic hips, long term follow up demonstrates a higher revision rate for THA in dysplastic hips, increased complication profile: infection, instability and neruovascular injury, risk of sciatic nerve injury if limb length changed by >4cm, may need to perform femoral shortening (trochanteric or subtrochanteric), weight loss, NSAIDs, activity modification, intra-articular injections, should not be performed in isolation as it does not treat underlying pathologic cause, hip arthroscopy performed concomitantly with PAO to address labral pathology or evaluate for chondral injuries, if significant chondral injury is identified, PAO can be abandoned with minimal morbidity, involves osteotomies in the pubis, ilium, and ischium near the acetabulum, allows significant three-dimensional correction of the acetabulum, hip arthroplasty performed after PAO may lead to increased incidence of a retroverted acetabular cup, make cut above acetabulum to sciatic notch and shift ilium lateral beyond the edge of acetabulum. The atlantoaxial joint is an important "transitional zone" in the cervical spine. 595 plays. Spine Infections, Tumors, & Systemic Conditions. Hip extension and knee flexion during exposure, Subtrochanteric femoral shortening osteotomy. (OBQ06.118) Figure 1 is the axial MRI image of the L5-S1 level from a patient with weakness, and left leg pain. It is inherited in an autosomal dominant fashion, Mutations in HME affect the prehypertrophic chondrocytes of the growth plate, It is caused by mutations in either EXT1, EXT2, or EXT3 genes, Radiographically, the exostoses are in direct connection to the medullary cavity, Radiographically, the exostoses grow towards the physis. common peroneal nerve. They attach to the patella (kneecap), which joins the four individual quadriceps muscles to one common tendon (Figure 2). During a minimally invasive total knee arthroplasty with a quadriceps-sparing approach, the exposure is found to be limited and causing difficulties with jig alignment. Thank you. Range-of-motion is from -5 degrees to 130 degrees. (SBQ12TR.9) A 67-year-old male is involved in a motor vehicle accident and presents with the closed orthopedic injuries shown in Figures A and B. (OBQ12.69) Patellar instability is a condition characterized by patellar subluxation or dislocation episodes as a result of injury, ligamentous laxity or increased Q angle of the knee. On the first post-operative day, the patient is noted to have weakness in ankle dorsiflexion with paresthesias over the dorsum of the foot. Clinical photograph and radiograph are shown in Figures A and B. Physical exam shows normal strength in all four extremities and hyper-reflexic patellar tendons. He also required a hemiepiphysiodesis when he was a teenager to correct an angular deformity of his lower extremity. She is neurovascularly intact in the bilateral lower extremities. depends on metaplastic bone (fibrocartilge) for successful results. He visits a geneticist and genetic screening reveals he has a EXT 1 gene mutation. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, 2019 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Pelvic Floor Rehab after Trauma - Kristin Phillips, PT (OTFC 2019, 4.5). Place all the apparatus parts together. Her new radiograph and MRI images are shown in Figure A and B respectively. Radiographs show a Tonnis angle of 15 degrees and a lateral center-edge angle of 15 degrees. (SBQ16HK.15) Orthobullets Team Trauma Her clinical mechanical alignment, patellar tracking, meniscal examination, and ligamentous examination are all equivocal on physical examination. Postoperatively, he has a significant limb-length increase with a foot drop. iliotibial band . A radiograph is shown in Figure C. What is the next step in management? Diagnosis is made with radiographs showing. Typically involving the posterior elements of the cervical spine. (OBQ11.236) (SBQ18SP.62) sessile or pedunculated lesions found on the surface of bones. WebCradle the affected lower leg in one arm. knee dislocation. Posterior spinal fusion with instrumentation, Anti-inflammatory medication and physical therapy, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, The David B. Levine, MD, HSS Spine Symposium 2020, Immediate Versus Delayed Surgical Treatment of Lumbar Disc Herniation for Acute Motor Deficits - Roger Hartl, MD, 2018 Orthopaedic Summit Evolving Techniques, Time for Surgery: The Pendulum has Swung too far - Stop Wasting Time, This is What I do - Scott D. Boden, MD (OSET 2018), Baylor College of Medicine Department of Orthopedics. He also has mild non-progressive weakness with ankle dorsiflexion on that side. He reports pain and paresthesias to the right buttock, posterolateral lower leg and lateral foot. articular extension present. Lumbar Disc Herniation is a very common cause of low back pain and unilateral leg pain, known as radiculopathy. The remaining physical exam is unremarkable, including normal achilles and patellar reflexes bilaterally, no clonus, and a down-going Babinski sign. In rare cases a large disc herniation can lead to Cauda Equina Syndrome which requires emergent diagnosis and treatment. Coughing and the Valsalva maneuver make the pain worse. WebLink to video demonstrating this. A 12-year-old skeletally immature female presents with a several year history of bilateral knee pain and lower extremity deformity with her knees rubbing together while she runs. When compared to a median parapatellar approach which of the following approaches may lead to higher rates of component malposition? Which of the following most accurately describes the outcomes of revision surgery in comparison to primary surgery? After a failure of nonoperative treatment, which of the following is the most appropriate surgical treatment? 93 plays. On strength testing, he has graded 5/5 strength to knee extension, most common deformities include. (OBQ13.27) A 44-year-old patient is presenting with right dorsal foot pain, loss of sensation, and weakness that started 3 weeks ago after moving large heavy boxes from his friend's apartment. Figure 21 shows the radiograph of a 32-year-old patient with right hip pain that has failed to respond to nonsurgical management. Diagnosis is confirmed clinically with genu valgum, knee contractures and presence of a patella that is dislocated posterolaterally. posterior dislocation - traction, extension, and anterior translation of the tibia (patellar tendon rupture, periarticular avulsion, or displaced menisci) may benefit from acute repair. anterior dislocation - traction and anterior translation of the femur. (OBQ10.254) Positive apprehension sign with lateral patellar translation. Treatment is closed reduction and casting or surgical fixation depending on the degree of displacement. estimated that 10% of all THA are performed as a result of dysplasia, breech presentation, female sex, primiparity, and family history, abnormal movement of the femoral head within the acetabulum due to both osseous and soft tissue abnormalities, leads to overload of the acetabular rim leading to secodnary OA, increased femoral anteversion, coxa valga, head-neck junction deformitites, femoral head asphericity, hypoplasia of the femoral intramedullary canal, posterior displacement of the greater trochanter, center of the femoral head should be at level of the greater trochanter, normal femoral neck anteversion: 15 relative to the femoral condyles, Proximal migration of head neck junction from inter-teardrop line <50% of femoral head vertical diameter. Neoadjuvant chemotherapy followed by surgical excision with subsequent adjuvant chemotherapy, Observation with serial radiographs every 6 months, Nail removal and surgical excision of the lesion. This is an AAOS Self Assessment Exam (SAE) question. (OBQ09.71) (OBQ06.20) Which of the following would most likely explain this clinical presentation. His patellar reflex is absent on the left, and 2+ on the right. recurrent torsional strain leads to tears of the outer annulus which leads to herniation of nucleus pulposis, lateral edge of posterior longitudinal ligament weakest region, common site for posterolateral/paracentral disc herniations, sinuvertebral nerves provide pain innervation to the posterior annulus, mediate vertebrogenic back pain that precedes or accompanies disc herniation, cellular senescence of fibrochondrocytes leads to loss of proteoglycan production leading to disc height loss, loss of height causes increased strain on the annulus fibrosus, increased strain leads to fissures of the annulus fibrils, annular tears compromise hoop stresses that act against the deforming forces of the nucleus pulposus, younger, well-hydrated discs more likely to herniate, pediatric patients may have Salter-Harris II fracture of the ring apophysis, older, desiccated discs less likely to herniate, sciatica symptoms result from combined mechanical compression and associated inflammation, not all patients with mechanical compression develop symptoms, TNF-, MMP, NO, PE2, and IL-6 are implicated in nerve irritation leading to radiculopathy, weak evidence to support DMARDs for treatment, Complete intervertebral disc anatomy and biomechanics, characterized by extensibility and tensile strength, high collagen / low proteoglycan ratio (low % dry weight of proteoglycans), low collagen / high proteoglycan ratio (high % dry weight of proteoglycans), proteoglycans interact with water and resist compression, a hydrated gel due to high polysaccharide content and high water content (88%), disc height dependent on the degree of hydration, nutrients supplied by diffusion from the end plates, key difference between cervical and lumbar spine is, cervical spine C6 nerve root travels under C5 pedicle, lumbar spine L5 nerve root travels under L5 pedicle, extra C8 nerve root (no C8 pedicle) allows transition, horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root, because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots, because of horizontal anatomy of cervical nerve root a central and foraminal disc will affect the same nerve root, may present with cauda equina syndrome which is a surgical emergency, affects the traversing/descending/lower nerve root, herniated disc material directly compresses dorsal root ganglion, can manifest with more severe pain than traditional posterolateral disc herniation, can affect both exiting and descending nerve roots, disc material herniates through annulus but remains continuous with disc space, disc material herniates through annulus and is no longer continuous with disc space, disc material is contained beneath the posterior longitudinal ligament, disc material passes dorsal to the posterior longitudinal ligament, important consideration given surgical outcomes are associated with chronicity, sudden onset of pain after lifting a heavy object, prolonged sitting with lateral bending and rotation in the presence of vibrational energy, symptomatic improvement lying supine with knees and hips flexed, especially with lower lumbar disc herniations, this may be discogenic or mechanical in nature, symptoms worsened by coughing, valsalva, sneezing, patient leaning away from side of radiculopathy, effort to increase the size of the neuroforamen, associated tenderness in the paraspinal musculature, dermatomal pain in the anteromedial thigh, dermatomal pain in the lateral thigh, crossing the knee, to medial foot, ankle dorsiflexion weakness (L4 > L5 contribution), have patient lie on side on exam table and abduct leg against resistance, dermatomal pain in anterolateral leg and dorsum of foot, have patient do 10 single leg toes stands, dermatomal pain in posterior calf and lateral foot, a tension sign for L4, L5 and S1 nerve root, most important and predictive physical finding for identifying who is a good candidate for surgery, crossed straight leg raise is less sensitive but more specific, femoral nerve stretch test (Wasserman sign), reproduction of pain in anterior thigh is considered positive, lower leg just to the point where pain recedes, ankle dorsiflexion causes exacerbated pain, SLR aggravated by compression on popliteal fossa, pain reproduced with neck flexion, hip flexion, and leg extension, pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins, pain reproduced with straight leg elevation for 30 seconds in the supine position, due to gluteus medius weakness which is innervated by L5, identify anomalous vertebrae (sacralized L5 or lumbarized S1), if present can changes surgical plan to involve fusion, lumbar spondylosis (degenerative changes), convex or concave list to the ipsilateral side of herniation, poor sensitivity for identifying disc herniation, more often used as a screening tool for other pathology prior to proceeding with MRI, sagittal and coronal reconstructions demonstrate compression of the thecal sac, myelography filling defect at the level of herniation, 93% accurate at detecting associated surgical pathology, unable to detect foraminal or extraforaminal herniations, infection (IV drug user, h/o of fever and chills), cauda equina syndrome (bowel/bladder changes), modality of choice for diagnosis of lumbar disc herniations, useful to differentiate from synovial facet cysts, however high rate of abnormal findings on MRI in normal people, need to correlate MRI findings with symptoms and physical exam findings, localize the level and side of the herniation, location anatomic location (central vs paracentral vs foraminal vs extraforaminal), first line of treatment for most patients with disc herniation, positive predictors of good outcomes with nonoperative treatment, second line of treatment if therapy and medications fail, no difference in pain relief using lidocaine with and without steroids, timing of appropriate nonoperative treatment varies, better surgical outcomes if addressed within 2 months, patients may return to medium to high-intensity activity at 4 to 6 weeks, outcomes with surgery compared to nonoperative, early and sustained pain relief out to 2 years, equal likelihood of receiving disability at 5 years, positive predictors for good outcome with surgery, weakness that correlates with nerve root impingement seen on MRI, progressively worsening symptoms prior to surgery, younger age, greater number of games played prior to injury, central and extraforaminal associated with worse outcomes, L5-S1 results in better outcomes than L2-3, negative predictors for good outcome with surgery, WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment, bedrest followed by progressive activity as tolerated, most modern protocols involve immediate activity with modification to avoid pain exacerbation, muscle relaxants (more effective than placebo but have side effects), modest but significant improvement in function, no significant improvement in pain, typically avoided due to complication profile, worse outcomes following surgical treatment, if used, usually for a short period (2-3 days) in the acute setting, typically initiated three weeks after symptom onset, extension exercises are extremely beneficial, most techniques can be performed in a "minimally invasive" fashion, can be done with small incision or through "tube" access, open technique using a crank (McCulloh) retractor, discectomy performed through microscope or loupe magnification, no difference in outcomes between the two, similar outcomes between all techniques surgical techniques, fragment excision vs extended disc space curettage (subtotal discectomy), lower long term back pain with fragment excision, higher reherniation rates with fragment excision at 2-years follow-up, can also be done with tubular or crank retractors, if have tear at time of surgery then perform water-tight repair, has not been shown to adversely affect long term outcomes, defined as recurrent sciatica at the same operated level, pain-free interval of 6 months prior to recurrence of symptoms, pathology can be ipsilateral to contralateral to the index presentation, revision rate at 8-year follow-up is 15% according to the SPORT trial, risk factors protective against recurrent herniation, revision microdiscectomy in patients with persistent symptoms, outcomes for revision discectomy have been shown to be as good as for primary discectomy, microscope usage proposed as a source of infection, treat with local wound care and antibiotics, scarring the compresses the dura leading to radicular symptoms, associated with poor outcomes following revision surgery, patients 3.2 times more likely to suffer from recurrent radiculopathy, MRI may demonstrate retraction of the dura on the side of the lesion, not completely understood but central sensitization may be a factor. 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