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acting simultaneously but the presence of one of
them alone may induce clinical manifestations.
e. Radiculopathy is the cause of lumbar disc herniation
and not the contrary.
D: There is evidence that mechanical deformation of the
nerve root as well as its chemical irritation due to lumbar
disc herniation are both causes of radiculopathy. However,
many studies have demonstrated that root compression alone
is capable of causing sciatica [82] by causing impaired blood
supply, edema, onset of compression and nerve suffering. On
the other hand, also chemical irritation may provoke
radiculopathy by itself via a direct biochemical effects of
nucleus components on nerve fiber structures and function,
inducing microvascular changes and inflammatory reactions
in the nerve [83].
54. In approaching a patient with high lumbar disc
herniation, which of the following anatomical
aspects should be considered:
a. The upper lumbar spine is similar to the L4-L5 and
L5-S1 levels.
b. The upper lumbar spine is characterized by
anatomically lager spinal canal.
c. The upper lumbar spine has the same density of
rootlets than the lower lumbar area.
d. Upper lumbar spine is characterized by narrower
laminas and isthmus, compared with those in the
lower lumbar area.
e. There are no anatomical differences between upper
and lower lumbar spine.
D: The definition of upper lumbar spine usually comprises
the levels from L1 to L4 [84]. This area presents a narrower
spinal canal than the lower lumbar area, with a major density
of rootlets and narrow laminas and isthmus. These are
important anatomical differences between the two segments
of the lumbar spine and they should be kept in mind when
surgically approaching lumbar spine.
55. For which reason fully endoscopic transforaminal
lumbar discectomy is more suitable for upper lum-
bar disc herniations than lower lumbar ones?
a. Because the higher lumbar space offers a larger
interlaminar space
b. The upper lumbar area has narrow isthmi, providing
higher instruments maneuverability.
c. The spinal canal is larger than in the lower lumbar
area, allowing for more room for endoscopic
movements.
d. The upper lumbar area has wide lumbar foramen,
offering more possibility for endoscope angulations.
e. There is no indication for fully endoscopic trans-
foraminal lumbar discectomy in the lower lumbar
area.
D: Endoscopic transforaminal lumbar discectomy is partic-
ularly indicated for herniation occurring in the upper lumbar
area because of the wider foramina diameter. This aspect
translates in more available space for endoscopic maneu-
verability, making the transforaminal endoscopic approach
for lumbar disc hernia removal more suitable in this area,
especially for upward migrated disc herniations [72]. In
upper lumbar area interlaminar space is not large and the
spinal canal is narrower than lower lumbar area.
56. Which one among the following is a percutaneous
endoscopic lumbar discectomy (PELD) systems?
a. YESS.
b. TESSYS.
c. A + b.
d. MIS-TLIF.
e. PLIF.
C: YESS stands for Yeung endoscopic spine systems that is
one of the most used system for PELD. The technology of
this system relies on the Kambin triangle as entry point for
the procedure. TESSYS stands for transforaminal endo-
scopic spine system and is a system for PELD as well. This
system, however, refers to a different entry point. In partic-
ular, the entry point for this system is the inferior interver-
tebral foramen. Both the systems are used for transforaminal
PELD approaches [85].
57. What is the role of transforaminal epidural steroid
injections for treatment of lumbar disc herniation,
according to NASS 2014 lumbar disc herniation
guidelines?
1. This conservative treatment modality does not carry
any benefits for the lumbar disc herniation patients
with radicular symptoms.
2. This conservative treatment modality carries the
same benefits of lumbar microdiscectomy.
3. This conservative treatment is superior to lumbar
microdiscectomy in terms of pain relief for the
patient.
4. This conservative treatment modality is recom-
mended by the NASS with the aim to provide
short-term (2–4 weeks) pain relief to patients with
lumbar disc herniation and radiculopathy.
118 T. Somma et al.
5. This conservative treatment modality presents a
lower efficacy rate in comparison to interlaminar
epidural steroid injections, in terms of pain relief.
D: According to NASS, trans foraminal epidural steroids
injections are recommended to provide short-term (2–
4 weeks) pain relief in patients with lumbar disc herniation
and radiculopathy. This recommendation presents grade A
evidence. Interlaminar epidural steroid injections may be
considered, but with a recommendation level C [69].
58. Which one among the following epidural steroid
injection modalities, has the strongest
recommendation?
a. Interlaminar.
b. Caudal
c. Transforaminal.
d. All the listed has the same level of recommendation.
e. None of the listed is recommended.
A: According to the 2012 North American Spine Society
Guidelines, epidural steroid injections are recommended in
non-surgical management of lumbar disc herniation, espe-
cially for short-term pain relief [69]. The results of 2 years
follow-up of 3 randomized double-blind controlled trials,
proved that interlaminar steroids injection are superior to the
transforaminal one at 12-months [86].
59. In a patient with clinical symptoms of radiculopathy
due to lumbar disc herniation, when is the optimal
timing for surgical intervention?
a. Prior to 2 months.
b. As soon as possible.
c. Prior to one year.
d. Prior to 6 months.
e. Timing does not affect the outcome.
D: According to NASS 2014 guidelines, best surgical
intervention timing in lumbar disc herniation patients is
within 6 months from the onset of clinical symptoms, with a
grade B recommendation. This is associated with a faster
recovery and improved in long-term outcomes [69].
60. Which one among the following localizations of
lumbar disc herniation is the most frequent?
a. Lateral intraforaminal.
b. Lateral extraforaminal.
c. Medio-lateral.
d. Medial
e. All the locations have the same prevalence.
C: The majority of lumbar disc herniations present a
medio-lateral localization (65%). This aspect has an
anatomical explanation due to the fact that the medial fibers
of the deep layer of the Posterior Longitudinal Ligament
(PLL) are firmly attached to the medial portion of the
annulus fibrosus, reinforcing this portion and making medial
lumbar disc herniations rare. On the lateral portion of the
annulus fibrosus, instead, they attach to the lateral membrane
that is a thin and translucent anatomical structure. Therefore,
the mediolateral portion of the annulus fibrous, the con-
junction point of the PLL and the lateral membrane, is to
consider as a point of weakness favoring the formation of
medio-lateral herniations [ 87 ].
61. In patients affected by lumbar disc he rniation, in
order to avoid recurrence:
a. It is suggested to always make discectomy along
with herniectomy.
b. Discectomy alone is enough because the freed space
is sufficient to obtain decompression, without
removing the herniated fragment.
c. The association of discectomy to the herniectomy
has not shown a clear advantage in terms of lumbar
disc herniation recurrence, so no clear indications
are present.
d. Discectomy associated with herniectomy has shown
to be detrimental, increasing the recurrence rate.
e. None of the listed sentences is true.
C: Recurrence of lumbar disc herniation is an important
issue with a mean prevalence rate ranging between 4 and
21% [88–90
]. According to the literature, the re-operation
rate do not clearly increase following removal of the herni-
ated material, with contrasting results among different
authors [88, 91]. Total removal of disc material leads to
reduced intervertebral disc space height, that can cause
segmental instability and acceleration of spondylosis, finally
causing failed back syndrome. Besides, preservation of
intervertebral disc reduces the risk of very life-threating
complications like abdominal or retroperitoneal
neuro-vascular structures injuries. For these reasons, the
opportunity of limiting the surgery to the herniectomy has
been evaluated in the literature with encouraging results in
terms of relapsing rate. Nevertheless, discectomy has shown
slightly better results in terms of low-back pain relief [88].
7 Degenerative Conditions of the Spine 119
At this moment, clear indications are lacking, and more
high-quality studies are needed with longer follow-up
periods.
62. Which one among the following radiological exams
is not useful in lumbar foraminal stenosis diagnosis?
a. Myelography.
b. Lumbar MRI.
c. Lumbar CT.
d. Plain radiographic lateral views.
e. Dynamic flexion and extension lumbar studies.
A: Myelography has a limited use in detecting lumbar
foraminal stenosis because is not able in depicting lateral
pathology for the reason that the dural sac terminates at the
lateral aspect of the midzone. As a consequence, that aspect
avoids contrast-fi lling of the distal nerve root sheaths. Plain
radiographs in the lateral views allow to depict the two most
important anatomical parameters for lumbar foraminal
stenosis diagnosis: posterior disc height (< 4 mm) and
foraminal height ( 15 mm). Dynamic flexion and exten-
sion lumbar studies are also useful in detecting dynamic
foraminal changes and stenosis. CT is precious in showing
bony encroachment into the foraminal area as well as the
presence of bony spurs. MRI is the gold standard providing
visualization of the foramen and at the same time a better
resolution on non-osseous components, namely interverte-
bral disc and paucity of perineural fat surrounding the nerve
root (in T1-weighted images) [92].
63. In a patient with foraminal stenosis:
a. Conservative treatment is not indicated.
b. Surgery is indicated also in asymptomatic patients.
c. Surgery just consists in foramen enlargement,
because other treatments are only more invasive but
do not impact clinical outcome.
d. Fusion surgery in always indicated in cases of
foraminal decompression.
e. Fusion surgery is necessary only in cases when
direct foraminal decompression does not provide
enough enlargement or when preoperative instability
is detected.
E: Patients with symptomatic Lumbar Foramen Stenosis
(LFS) are primarily treated conservatively. In cases of failure
to improve a surgical foraminal enlargement should be
performed and, in cases of failure, a fusion surgery can be
performed. However, the latter should be conceived as first
strategy in cases of significant preoperative instability [93].
64. Which one among the following sentences regarding
the clinical presentation of lumbar spinal stenosis is
true?
a. Patients do not present with radiculopathy.
b. Lumbar stenosis is not always symptomatic. Patients
can also present without symptoms.
c. Neurogenic claudication is a rare manifestation of
spinal stenosis.
d. Low back pain is almost always present among
lumbar stenosis patients.
e. All the listed sentences are true.
B: Lumbar stenosis is a chronic degenerative alteration of
lumbar spinal canal with spinal cord or nerve compression.
Neurogenic claudication is the cardinal symptom of this
pathology, while low-back pain is not always present. Pain
improves when bending forward and is alleviated by sports
like bicycling, since during this sport the trunk is flexed
forward [94]. Some patients can also present with a
radiculopathy that persists during resting worsening during
the night.
65. A 70 years old patient comes to your attention with
a clinical picture of mild low-back pain, worsening
in supine position and improving in sitting position.
The main complaint referred by the patient is a
severe gait fatiguability, making him unable to walk
for more than 100 m without resting. After resting,
however, he can restar t again without leg pain. His
walking autonomy is longer in anterior bending
position and on uphill. Moreover, the patient refers
that bicycling is less a problem for him than walk-
ing. On clinical examination, he presented
hyporeflexia, without sensibility or strength alter-
ations, with worsening of lumbar pain during back
extension maneuvers and Straight Leg Test nega-
tivity. Lumbar MRI is showed in the figure. Which
is the diagnosis for this patient?
a. Lumbar stenosis.
b. Lumbar disc herniation.
c. Spondylolisthesis.
d. Spondylodiscitis
e. None of the listed hypothesis is true.
120 T. Somma et al.
A: The clinical scenario and the magnetic resonance imaging
is compatible with a diagnosis of lumbar stenosis. The
patient does not present signs of radiculopathy or infection.
Moreover, the aspects of the pain, that improves with lumbar
anterior flexion and worsens with spine extension is typi-
cally associated with degenerative lumbar stenosis. Con-
trariwise, spondylolisthesis presents with pain improving
during physical effort. Finally, patients with lumbar stenosis
use to better perform bicycling and uphill walking, because
both require spine flexion, enlarging intracanal space and
reducing spinal cord compression. Magnetic resonance
shows an L3-L4 lumbar stenosis, that is also compatible with
the neurol ogic examination [95].
66. Considering MRI pictures of question number 56,
which one among the following classification scales is
the most suitable to define its severity?
a. MSU classification.
b. Meyerding system.
c. Schizas system.
d. Modic system.
e. None of the listed system has been improved for this
pathology.
C: The patient presented in question number 56 is affected
by lumbar stenosis. Schizas classification represents a
qualitative grading system based on the morphologic
appearance of the dural sac as seen in T2-weighted axial
images of the lumbar spine. Many radiological evaluation
systems have been developed, most of all concerning almost
exclusively about spinal canal diameter measurements, such
as the surface measurement methodology or the stenosis
ratio system [96]. The Schizas’ system is different from these
methodologies because it focuses on morphological param-
eters. This classification systems identifies 4 different grades
of stenosis severity, based on CSF morphology: Grade A,
describes the condition where CSF is clearly visible but has
an inhomogeneous aspect; Grade B consider the case where
CSF is slightly present and rootlets occupy the whole dural
sac area, but they are still individualized; Grade C is the case
where no rootles are recognizable and no CSF signal is
detectable, making the dural sac showing an homogeneous
gray signal; Grade D patients, on the other hand, present
with no rootles recognizable with no epidural fat posteriorly
[97].
67. The clinical history of a patient with spinal stenosis
usually consists in:
a. An acute onset with intense lumbar pain and
sciatica.
b. An acute onset with only sciatica.
c. Chronic course of mild low back pain interspaced
with critical episodes of lumbar painful blockage,
worsening during the bending position and coupled
with falling due to hyposthenia.
d. Chronic course of numbness, weakness and dis-
comfort in the legs while walking or prolonged,
usually without a long history of low back pain.
e. None of the following sentences describes the typ-
ical clinical picture of lumbar stenosis.
D: Lumbar spinal stenosis is a chronic condition, typically
manifesting with neurogenic claudicatio, with regression of
the symptoms during sitting, resting and forward bending.
An acute onset is rare and if present the diagnosis should be
reconsidered, except in the cases of patients with a con-
genitally narrow canal that can develop major neurologic
deficit in a brief period due to the insurgence of an additional
disc protrusion [98].
68. Which one among the followings sentences is not
true regarding the anatomy of lumbar foramina?
a. Vertebral pedicles contribute to form the anterior
wall of the lumbar foramina.
b. Superior articular facet composes the posterior wall
of the foramina.
c. Intervertebral discs participate in the composition of
the anterior wall of lumbar foramina.
d. Inferior articular facet composes the anterior wall of
the foramina.
e. Ligamentum flavum participates in the formation of
the posterior wall of the foramina.
D: Intervertebral foramina are oval or round anatomic
structures, forming between upper and lower vertebra, that
contains the emergence of nerve roots. They present anterior
and posterior boundaries. The anterior profile is made by
adjacent superior-inferior vertebral pedicles, the posteroin-
ferior margin of the superior vertebral body, the interverte-
bral disc, the postero-superior margin of the inferior
vertebral body. Posterior foraminal boundary is made by the
ligamentum flavum and the superior and inferior articular
facets [93].
69. Which one among the following radiological aspects
of the nerve root is indicative of lumbar foraminal
stenosis (LFS) on MRI?
a. The paucity of perineural fat surrounding the nerve
root.
7 Degenerative Conditions of the Spine 121
b. The excessive posterior deviation of the nerve root
direction in exiting the foramen, depicting an obtuse
angle.
c. The excessive anterior bending of the nerve root in
exiting the foramen, depicting a pathologically acute
angle.
d. The reduction of the nerve diameter < of 2 mm.
e. None of the listed has a value in determining
foraminal stenosis.
A: MRI is an important tool in diagnosis of LFS, mainly
because it a llows to gain information regarding both
foraminal alterations and central canal narrowing, at the
same time. Moreover, it allows to define the degeneration of
intervertebral discs and vertebral bodies. The most indicative
sing of LFS on parasagittal MRI images is the loss of per-
ineural fat surrounding the nerve root [93]. Nerves direction
deviations are better visible on MR myelography. Nerve root
swelling and increased diameter are more likely associated
to LFS than diameter reduction [99].
70. In evaluating the lumbar foramen on plain radio-
graphs of a patient suspected for lumbar foraminal
stenosis (LFS):
a. Posterior disc height < 4 mm.
b. Foraminal height 15 mm.
c. a + b.
d. Kyphotic grade of lumbar lordosis < 5°.
e. None among the listed sentences is true.
C: Plain radiographic lateral views have shown to detect the
lowering of posterior disc height (< 4 mm) and the foraminal
height (< 15 mm) [100].
71. A 65-year-old male patient comes to your attention
reporting left leg pain and paresthesia in a crural
distribution. The symptoms are present during rest,
worsen during gait, reaching a peak always after
200 m. Moreover, he refers that pain improves with
anteflexion of the trunk and intensifies while lying,
especially whit left side decubitus. Clinical evalua-
tion shows weakness in reflex elicitation at the left
side, and ante-flexed trunk gaiting. Kemp’s sign was
present on the left side, reproducing radicular
symptoms early. Which one is the most probable
pathology affecting this patient?
a. Radiculopathy secondary to lumbar disc herniation.
b. Central canal lumbar stenosis.
c. Neurogenic claudication with radiculopathy, due to
lumbar foraminal stenosis.
d. Isthmic spondylolisthesis.
e. None of the listed hypothesis is correct.
B: Lumbar foraminal stenosis (LFS) is a common degener-
ative alteration of the lumbar spine, causing radicular pain
and neurogenic claudication, mainly due to degeneration of
the intervertebral disc. This degeneration, indeed, associates
to anterior or posterior subluxation of the superior articular
process of the inferior verte bra, leading to reduction of the
foramen height and thus foramen area. From a clinical point
of view, this pathology presents predominantly with radic-
ular leg pain and limited lumbar range of motion, especially
in extension. Typically, leg pain often presents a dermatomal
distribution with the aspects of an entrapping nerve pathol-
ogy. In fact, in affected patients, pain is triggered by lumbar
extension, in particular on the affected side, by sitting or by
supine position, for example during bed lying. Contrariwise,
it improves with anterior flexion of the trunk [101]. These
aspects explained considering that lumbar foraminal stenosis
is the result of both fixed anatomical anomalies and dynamic
factors. In particular, cadaveric studies clearly showed that
spine extension decreases all foraminal dimensions by an
average of 15% while flexion causes a significant average
increase of 12% [102]. In cases of lumbar disc herniation,
compression causes neural distraction, provoking a pain that
worsens during trunk flexion and tension-based sings, war-
ranting Las é gue test positivity [93
].
72. Lumbar MRI of the patient at the question 71
showed an L2-L3 left foraminal stenosis. W hich type
of foraminal stenosis is the one that affected this
patient?
a. Transverse foraminal stenosis.
b. Vertical foraminal stenosis.
c. Circumferential foraminal stenosis.
d. Half circumscriptive stenosis.
e. None of the listed is a possible category of foraminal
stenosis.
C: Lumbar foraminal stenosis (LFS) is a common degener-
ative alteration of the lumbar spine, mainly due to reduction
of the foraminal area and height, that is often clinically and
radiologically unrecognized. Anatomically, three major
types of LFS can be distinguished. Vertical stenosis, featured
by craniocaudal compression of the exiting nerve, exerted by
posterolateral osteophytes and herniated disc at the same
time, pushing the root against the superior pedicle. Trans-
verse stenosis defines the cases of a subluxation of the
superior facet is and associated to a hypertrophic ligamen-
tum flavum and/or bony spurs that simultaneously partici-
pate in root compression on a transversal plane.
122 T. Somma et al.
Finally, the circumferential stenosis characterized by a
combination of the described compression mechanisms. The
distinctive elem ent individuating this category is the absence
of intraforaminal fat in both, anterior and posterior portion of
the foramen. Therefore, the patient in the clinical case is
affected by a circumferential foraminal stenosis [93].
73. In the management of lumbar foraminal stenosis:
a. Electrophysiological preoperative studies are always
indicated, independently to the extension and loca-
tion of the peripheral disorder.
b. Plain radiographs are not useful anymore because no
information’s regarding the foramen pathology are
provided.
c. After foraminal decompression, spine fusion is
advisable in the majority of cases considering that
foraminal decompression leads to spine instability.
d. In cases of patients affected by both, foraminal and
intra-canalar stenosis, intraoperative electrophysiol-
ogy may be useful.
e. Lumbar foraminal stenosis has primarily to be sur-
gically treated.
D: In some cases, lumbar foraminal stenosis (LFS) also
associates with an immediately higher medial canal stenosis,
depicting a clinical pathological situation called “double
crash” lesion. In these cases, it can be difficult to understand
which one among the two pathological alterations is the
main responsible for the symptomatology. In these cases,
intraoperative electrophysiology may be helpful in over-
coming this problem by measuring the distal latency of the
spinal nerve to compare intracanal and extraforaminal
lesions [103]. Electrophysiological preoperative studies are
useful in clinical management of this pathology. However,
they are not always applicable because they can lead to false
positive results when Wallerian degeneration does not
extend below the knee. Plain radiographs are still useful in
foraminal stenosis management setting because they allow to
gain precious infor mation regarding posterior disc height
and foraminal height that, in cases of pathological reduction,
are indicators of potential LFS. After practicing foraminal
surgical decompression, spinal fusion is not advised as
default but is restricted to the cases when also spinal insta-
bility has been detected. Usually, in cases of lumbar
foramina stenosis, conservative treatment is the first line
treatment of choice, leaving surgical management for the
cases where conservative treatment has failed [93].
74. Speaking of lumbar stenosis, the narrowing:
a. Is located into the central spinal canal.
b. Is located in the central spinal canal and in the
neural foramina. Cases of only central spinal canal
narrowing are called incomplete lumbar stenosis.
c. Can be located in the central spinal canal and/or the
neural foramina and/or under the facet joint (sub-
articular stenosis).
d. Can be located in the central spinal canal and/or the
neural foramina and/or under the facet joint (subar-
ticular stenosis), also involving the interlaminar space.
e. Has to be located just in the foramina.
C: In patients affected by lumbar stenosis, the narrowing
may involve the central spinal canal, the neural foramina
(foraminal stenosis) but also the area under the facet joint
(subarticular stenosis) [ 104].
75. In the surgical treatment of lumbar stenosis:
a. Decompression alone is more effective than
decompression and fusion in relieving pain.
b. Decompression alone is generally not enough in
obtaining pain relief and fusion should always been
associated.
c. There is no advantage in associating fusion to
decompression in treating lumbar stenosis.
d. Decompression and fusion have shown to be more
effective in relieving pain in comparison to decom-
pression alone, but only in cases of lumbar stenosis
due to spondylolisthesis.
e. Decompression and fusion are more effective than
decompression alone.
D: According to the literature, decompression along with
fusion is a more effective strategy than decompression alone
in treating pain and in increasing functional status, but only
in patients with lumbar stenosis associated to spondylolis-
thesis [105]. The same benefit has not been achieved in cases
of lumbar stenosis without spondylolisthesis [
106].
76. In patients affected by lumbar stenosis, the most
typical clinical sign is neurogenic claudication, that
improves in lumbar flexion. Which one among the
following may be a possible explanation?
a. Extension of the spine reduces the cross-sectional
area of the central canal as well as of the neural
foramina stretching the myelin of the intr aforma-
tional tract of peripheral spine nerves and slowing
nerve conduction.
b. Flexion of the spine moves forward the center of
gravity, moving the body weight from the hips to the
ankle, reducing in this way axial and groin pain.
7 Degenerative Conditions of the Spine 123
c. Extension of the spine obstacles the liquor pathways
to the medulla, causing catabolites accumulation in
the spine and lack of anabolites, inducing spinal
suffering and pain.
d. Extension of the spine reduces the cross-sectional
area of the central canal as well as of the neural
foramina, exerting further pressure on the veins
surrounding the nerve roots, leading to nerve com-
pression. Spine flexion inverts this process.
e. Extension of the spine reduces the cross-sectional
area of the central canal as well as of the neural
foramina, exerting further pressure on the arterioles
surrounding the nerve roots, leading to nerves suf-
fering. Spine flexion is able to invert this process.
D: Typically, patients affected by lumbar stenosis present
with neurogenic claudication that improves with rest and
spine flexion. Moreover, these patients usually better tolerate
exercises performed during lumbar flexion, such as cycling
[104]. Extension of the spine reduces the cross-sectional area
of the central canal and of the neural foramina, exerting
further pressure on the veins surrounding the nerve roots,
leading to nerves engorgement and ischemic suffering. Spine
flexion is able to invert this proces s [107].
77. In patients with lumbar stenosis surgically treated
for decompression:
a. Physical therapy is contraindicated in the
post-operative management because it results
dangerous.
b. Physical therapy is indicated but it useful only if
started at least two months after surgery.
c. Physical therapy has shown to be useful in the
post-operative management, independently to the
post-surgical starting time.
d. Physical therapy has shown to be useful in the
post-operative management, when started six weeks
to three months after surgery.
e. Physical therapy is superior to surgical treatment in
all cases of degenerative lumbar stenosis.
D: The role of physical therapy in the post-operative period
is supported by randomized controlled trials, showing that
active rehabilitation started from six weeks to three months
after surgery is more effective than standard care in
long-term improvement of functionality, low back pain and
leg pain [108].
78. Regarding the preoperative factors to consider in
predicting post-surgical outcomes in lumbar spinal
stenosis, which one among the following is incorrect:
a. Patients’ age has a strong impact on the outcomes
because older patients have shown worse outcomes
in comparison to younger ones.
b. Depression is associated to worse outcomes.
c. Smoking impacts post-operative outcomes.
d. Preoperative leg pain is associated with more evi-
dent post-operative improvements
e. Obese patients have worse post-surgical outcomes.
A: Obesity, smoking habit and preoperative depression are
detrimental for post-surgical patient course. Age and gender,
however, have proved to have no impact in determining
post-operative outcomes [109].
79. In endoscopic laminectomy for treatment of lumbar
stenosis, which one among the following is a possible
starting point?
a. Kambin triangle in the intervertebral foramen.
b. Inferior intervertebral foramen.
c. Superior articular process.
d. Inferior articular process.
e. None of the listed.
C: Endoscopic corridors for treating lumbar stenosis requires
an higher starting point. Kambin triangle is the entry point
for YESS (Yeung endoscopic spine system) and inferior
intervertebral foramen is the entry point for TESSYS
(Transforaminal endoscopic spine system), which are two
PELD (percutaneous endoscopic lumbar discectomy)
modalities, that have the common goal of approaching the
intervertebral disc. For this reason, their viewing window is
not suitable for practicing a laminectomy. The superior
articular process is more indicated [110].
80. Sagittal Balance has shown to be strictly correlated
with spinal pathology. In particular, lumbar lordosis
(LL) has shown to be strongly correlated with low
back pain. How does this parameter change with age
and how is it correlated with low back pain?
a. This parameter decreases with age. A decreased
lumbar lordosis increases the risk of low back pain
because the two elements are connected by an
inverse correlation.
124 T. Somma et al.
b. This parameter increases with age and increased
lumbar lordosis reduces the risk of low back pain.
c. This parameter decreases with age and the same
does the risk of developing low back pain consid-
ering that this risk is directly correlated to the grade
of lumbar lordosis.
d. This parameter increases wi th age and the same dose
the risk of low back pain because the latter
increasing proportionally at the increasing of the
former.
e. Lumbar lordosis does not affect the risk of devel-
oping low back pain.
A: Loss of the lumbar lordosis is a distinctive finding in the
aging spine, leading to an increased prevalence of low back
pain (LBP). In fact, patients with LBP tend to have an
attenuated lumbar lordosis compared to healthy patients
[111].
81. According to WFNS 2020 guidelines, which among
the following radiological parameters is considered
as cut-off for central lumbar canal stenosis
definition?
a. Anteroposterior canal diameter < 10–15 mm.
b. Anteroposterior canal diameter < 4–5 mm.
c. Cross-sectional area < 75–145 mm
2
.
d. a + c.
e. b + c.
D: According to WFNS 2020 guidelines, an antero-posterior
canal inferior than 10–15 mm and/or a cross-sectional area
inferior than 75–145 mm
2
should be considered as cut-off
values to define central stenosis [112].
82. Which one among the following is not a suitable
surgical approach in treating lumbar stenosis?
a. Laminectomy.
b. Bilateral laminotomies.
c. \.
d. Laminoplasty.
e. Bilateral decompression through unilateral
laminotomy.
C: Laminectomy, bilateral laminotomies, bilateral decom-
pression through unilateral laminotomy and laminoplasty are
all surgical techniques indicated in lumbar stenosis accord-
ing to WFNS 2020 guidelines. YESS is a PELD
(percutaneous endoscopic lumbar discectomy) technique
that does not allow endoscopic canal decompression [110,
112, 113].
83. According to the WFNS 2020 guidelines for spinal
stenosis, which one among the following is the best
surgical management of a patient with lumbar
degenerative spinal stenosis, with loss of sagittal
balance and related symptoms?
a. Decompression alone in sufficient.
b. Decompression and associated fusion is necessary.
c. Decompression, fixation and deformity correction
are all indicated.
d. There is no difference among the approaches.
e. There is no consensus regarding this issue.
C: According to the WFNS 2020 guidelines, in cases of
lumbar degenerative spinal stenosis with concom itant loss of
sagittal balance and related symptoms, decompression
should be coupled with fixation and deformity correction
[112].
84. Which one among the following spinal decompress-
ing techniques allow preservation of posterior
elements?
a. Standard posterior laminectomy.
b. Bilateral laminotomy.
c. Unilateral laminotomy with bilateral decompression.
d. a + c.
e. b + c.
E: Standard posterior approach with open laminectomy and
facet sparing is the only one approach among the listed that
contemplate the whole resection of posterior elements (spi-
nous processes and laminas). Bilateral laminotomy allows
the preservation of pars of the laminas and the spinous
process. In the unilateral laminotomy with bilateral decom-
pression technique, part of the lamina on one side, the whole
lamina on the opposite side and the whole spino us process
are preserved [114].
85. According to 2020 WFNS recommendations for
lumbar stenosis surgical treatment:
a. Microscopic techniques are equal to standard
laminectomy in achieving adequate spinal canal
decompression.
7 Degenerative Conditions of the Spine 125
b. Microscopic techniques are more effective than
standard laminectomy in achieving adequate spinal
canal decompression.
c. Standard laminectomy is more effective than
microscopic techniques in achieving adequate spinal
canal decompression.
d. There is no consensus regarding the best technique
for spinal decompression in lumbar spine degener-
ative stenosis.
e. WFNS recommendation does not mention about
best surgical decompression technique in cases of
lumbar stenosis.
D: The WFNS spine committee does not reached a con-
sensus regarding the most indicated decompression tech-
nique for lumbar stenosis. For this reason the choose is still
left to the surgeons according to their preferences [114].
86. According to 2016 NASS guidelines, which is the
definition of “isthmic spondylolisthesis”:
a. The anterior translation of one lumbar vertebra over
the next inferior segment as a result of a lesion of the
pars inte rarticularis.
b. The anterior translation of one lumbar vertebra over
the next inferior segment as a result of the rupture of
a vertebral hemangioma.
c. The anterior translation of one lumbar vertebra over
the next inferior segment as a result of spinal disc
degeneration.
d. The anterior translation of one lumbar vertebra over
the next inferior segment as a result of a lesion of the
facet joints, generating lumbar spinal and/or
foraminal stenosis.
e. The anterior translation one lumbar vertebra over the
next inferior segment as a result of a lesion of the
posterior ligamentous complex, generating lumbar
spinal canal and/or foraminal stenosis and a clinical
picture of claudicatio and hyporeflexia.
A: According to 2016 NASS guidelines, isthmic spondy-
lolisthesis is the anterior translation of one lumbar vertebra
over the next inferior segment as a result of a lesion of the
pars interarticularis, regardless to the presence of spinal
canal or foraminal stenosis and a compatible clinical picture
[115]. Vertebral hemangiomas are well described benign
lesions of the spine consisting in a pathological proliferation
of normal thin-walled capillary , cavernous or venous vessels
within the marrow space and the bony trabeculae of the
vertebra [116]. Only rarely they cause isthmic spondylolis-
thesis [ 117].
87. In treating a patient with lumbar degenerative
spondylolisthesis, according with 2014 NASS
guidelines:
a. Conservative treatment is not advised.
b. A first try with conservative treatment is suggested,
independently from the severity of
spondylolisthesis.
c. Conservative treatment is a valid option in patients
with low-grade spondylolisthesis and low back pain.
d. Conservative treatment is indicated as a first-line
treatment in patients with low-grade spondylolis-
thesis and low back pain, but only in cases where
neurological deficits are absent.
e. The 2014 NASS guidelines do not mention con-
servative treatment for spondylolisthesis.
D: 2014 NASS guidelines suggest conservative management
as first-line therapy only in patients affected by low-grade
spondylolisthesis and low back pain, but without neurolog-
ical deficits [118].
88. Which ones among the following are main clinical
signs of spondylolisthesis?
a. Back pain worsening during motion and meliorating
with rest. The presence of leg pain indicates another
diagnosis.
b. Back pain and leg pain worsening during motion
and improving with rest.
c. Constant back pain, worsening especially during
night. The aspect of pain that improves during rest
should move toward another diagnosis.
d. Constant leg pain, worsening with nerve stretching
maneuverers.
e. Neurological claudication.
B: The cardinal symptoms of spondylolisthesis are
mechanical low back pain, namely a pain that worsens with
motion and improves with rest, and leg pain [119]. They are
thought to be the result of abnormal distribution of load
across the vertebral endplates. Constant back pain worsening
especially at night time is more typical of tumoral vertebral
lesions, like spinal metastasis [120], while leg pain with
crural or sciatic distribution, especially exacerbated by nerve
stretching maneuverers like Wasserman or Laségue, is
126 T. Somma et al.
indicative of nerve root inflammation and compression,
usually due to intervertebral disc herniation [69].
89. Which one among the following is the best clinical
test for diagnosis of facet joint pain syndrome?
a. Kemp’s test.
b. Quadrant test
c. Extension-rotation test.
d. All of the above are different names for the Kemp’s
test.
e. None of the listed tests.
The Kemp’s test has shown to be a clinical test useful for
clinical diagnosis of facet joint syndrome. This test has been
described with different names, such as Quadrant test and
extension-rotation test [121, 122].
90. Regarding low back pain in patients affected by
spondylolisthesis, which one of the following
descriptions of the pain is correct?
a. pain is constant and does not change with posture or
motion.
b. pain improves with rest and worsens with motion.
c. Pain is more intense during the night, improving
when patient wakes up starting his/her daily
activities.
d. Pain does not ch ange with changes in position, but it
is worse at rest.
e. None of the sentences are true.
B: One of the main symptoms affecting spondylolisthesis’
patients is mechanical low back pain., namely a pain that
worsens during motion and changes from sitting to standing
position, and improves with rest. It is considered to be due to
an abnormal distribution of load across the vertebral end-
plates following disc degeneration [123].
91. A thirty-six-years-old patient comes to your atten-
tion referring long history of low back pain, worse
during physical demanding activities and improving
with rest, forcing the patient to rest after walking for
less than 200 m. A seven months pharmacological
therapy with both steroids and not steroidal drugs
has led to poor improvement. Mri of the lumbar
spine depicts a grade 1 spondylolisthesis according
to Meyerding classification, and lumbar stenosis.
Which one among the following treatment strategies
may lead to a better clinical outcome?
a. Physiotherapy.
b. Steroids infiltrations.
c. Surgical management with laminectomy alone.
d. Surgical management with laminectomy and fusion.
e. Surgical management with no differences among
laminectomy alone and laminectomy and fusion.
D: The Spinal Laminectomy versus instrumented pedicle
screw (SLIP) trial showed that laminectomy with the
addiction of fusion is superior to laminectomy alone in
patients affected by grade 1 spondylolisthesis with lumbar
stenosis[124]. When a 3–6 months of conservative treatment
does not show results in spondylolisthesis patients,
laminectomy and fusion is the most suitable option [118].
92. In surgical treatment of lumbar degenerative
spondylolisthesis, according to the most recent
guidelines and clinical trials:
a. Instrumentation must always be considered after
decompression and fusion, due to the peculiar
pathogenetic pattern of the pathology, to prevent
recurrences.
b. After decompression and fusion, instrumentation
should be avoided in considerat ion of the exces-
sively high complication rate.
c. Instrumentation after decompression and fusion has
shown to be effective in improving patients’ clinical
outcome but not the fusion rates.
d. Instrumentation after decompression and fusion has
shown to be effective in improving fusion rates, but
without effects on clinical outcomes.
e. Instrumentation after decompression and fusion has
shown to be effective in improving clinical out-
comes, without effects on fusion rates.
D: Studies have shown statistical significant evidence that
fixation improves fusion rates without affecting clinical
outcomes [124]. Instrumentation is notably associated to
longer operations and more blood loss than decompression
and fusi on alone [125] and according to 2016 NASS
guidelines for surgical treatment of lumbar degenerative
spondylolisthesis, instrumentation is only indicated to
improve fusion rate but not with the aim of obtaining a better
surgical outcome [126].
93. In surgical treatment of lumbar degenerative
spondylolisthesis, in comparison to open fusion
techniques:
a. Minimally invasive surgery (MIS) is not recom-
mended because it has not reached yet a sufficient
level of efficacy in terms of clinical outcomes.
7 Degenerative Conditions of the Spine 127