[oldracer]

#6868

Dr.Corenman below is my back history:
I am a 68 year old male with a history of back problems. My back problem began in 2005 while replacing a broken fence post. After 3 years of being told it was nothing more then a muscle strain, I was x-rayed in May 2008. The results of the x-ray were:
FINDINGS: “There are five lumbar-type vertebral bodies with normal vertebral height. Diffuse mild to moderate degenerative disk disease of the lumbar spine, most severe at L5-S1 is seen. Chronic defect of the bilateral pars of L5 with Grade 1 spondylolisthesis, 9.7 to 10 mm is identified”.
From June 2005 to the end of 2011 I have tried multiple sessions of physical therapy and other forms of treatment. They keep the pain manageable but in February 2012 I slipped and twisted my back. Ever since then it has been hard to manage the pain. I am becoming more dependent on pain medications. It should be noted That I have two other chronic diseases that should be noted. 1.) Rheumatoid Arthritis diagnosed in 2007. 2.) Glaucoma diagnosed in 1998.
In May 2012 it was decided that I should have a MRI done on my back, with the following results: FINDINGS:
At T11-12, very mild disk space narrowing. Minimal bulging disk. No significant central stenosis.
At T12-l1,L1-2, and L2-3 no significant abnormality is seen.
At L3-4, mild disk space narrowing. Bulging disk. Very mild narrowing of the central canal. Left-sided intraforaminal disk herniation moderately narrows the left intervertebral foramen. Right foramen is mildly narrowed.
At L4-5 mild disk space narrowing. Bulging disk. Small central disk herniation minimally indents the anterior contour of the thecal sac at the disk space level. Mild bilateral foraminal stenosis.
At L5-S1 severe disk space narrowing. Grade 1 anterolisthesis of L5 on S1. Bilateral pars interarticularis defects at L5. Central canal appears patent. Severe bilateral foraminal stenosis.
Bone marrow, lower thoracic cord, conus, and paraspinal soft tissues are unremarkable.
IMPRESSION:
Mild disk disease at L3-4 and L4-5. Mild central canal narrowing at this level. Left-sided intraforaminal disk herniation at L3-4, could affect L3 root.
Bilateral pars interarticularis defects at L5 with grade 1 anterolisthesis. No significant central stenosis. Severe bilateral foraminal stenosis. Correlate with L5 symptoms.

With that somewhat dismal assessment it’s a wonder I can stand up!

In late may I had a spinal epidural, but because of my glaucoma they could only give me 6mg of the normal 49mg medication. The epidural only lasted about 3-4 weeks.

So I’m now at a point to decide if I should consider back surgery. I can probably deal with the back by continuing my back exercises and staying active for several years. I am in good overall health and up until recently very active.
My questions are as follows:
1.) Should I consider back surgery now while I’m in good health and I can handle the rehabilitation, versus several years from now when I’m in my 70’s.
2.) The MRI did not indicate if the slippage of L5 had progressed, no distance referenced. Should I find out if it’s progressed to help in my decision? How do I do that?
3.) Given this information what procedure or other approach would be the best to consider.
4.) Could the Bilateral pars interarticularis defects at L5 be when my R.A. actually started (2005)? Since the synovium lining of the facet joint is the same as in the joints of my hand that the Rheumatoid Arthritis attacks

[Donald Corenman, MD, DC]

#6871

You have had the isthmic spondylolisthesis since you were about 10 years old most likely. This disorder has been quiescent until you tore some of the restraining scar tissue 7 years ago replacing that fence post. In many cases unfortunately, once the spondylo becomes painful, you can’t put the genie back into the bottle. Februrary of this year with that slip, more of the pannus tore (see website under isthmic spondylolisthesis to understand this concept).

Rheumatoid arthritis does occasionally affect the facet joints but less commonly in the lumbar spine. Interestingly in your case, the facets at L5-S1 are not loaded due to the pars fracture from the spondylolisthesis. It would be very rare to have facet pain from the L5-S1 segment even if these facets were involved with rheumatoid arthritis.

The chance of further slippage is highly unlikely in your case. Your disc at L5-S1 is very degenerative which almost “interlocks” L5 to the S1 segment. (Radiologist; “At L5-S1 severe disk space narrowing’).

I think there are occasions where waiting for surgery is a good idea but at your age with your diagnosis and history, this is not one of them. I agree that you would be healthier now than in 5 years and with your history of 7 years of pain, this condition is unlikely to improve.

You need a workup to determine the pain generator but I think based upon your limited history and MRI findings, the most likely pain generator is going to be the L5-S1 level. If that is the case, you would do well with a TLIF fusion of that level. See the website for further details of that procedure.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[oldracer]

#6875

Dr. Corenman, thak you for answering my questions. I did research the Lumbar Fusion Types at this site, but I have a couple of questions.

The TLIF uses a 2 1/2 inch incision on only one side. Why only one side, it would seem logical to do both sides. It also says there is risk of heterotopic bone formation and nerve root irritation. How ofton does this happen and is it permanate?

The MIS-TLIF is designed to preserve the muscles around the segments being fused, but it goes on to say “Since the two vertebrae are going to be fused together, there is no reason to preserve these muscles and actually significant reasons to move them”. Is that supose to say “remove them” I’m a little confused on this one!

MIMS-TLIF is this refered to as a “open surgery”? Would my degenerative spondylolisthesis require the decompression this procedure allows?

Also, what questions should I be prepared to ask my spine surgon regarding his qualifications and the procedure he recomends?

Is there a way to research your spine surgon for qualifications other than the internet?

Finally, I would like to comend you for the great srevice you provide to those of us who suffer with back problems. I use this web site to educate myself and other family members about my condition. It is much appreciated.

[Donald Corenman, MD, DC]

#6876

I am finishing my paper on BMP complications now. BMP used properly appears to have about a one to two percent complication rate for heterotopic bone formation (not verified just yet). This also might be related to technique. Most of the time, the effects are transient.

You will find in the spine field that “minimally invasive” is the new flashy term that some surgeons are promoting. Fads unfortunately are common in the spine field and this is one of them. The two incisions made for “minimally invasive spine surgery” actually add up to a longer total incision than a small central incision and the scars are more unsightly in my opinion.

The purpose to “preserve spinal muscles” also makes no sense in this case. The purpose of the TLIF is to fuse the two segments together. The muscles that join these two segments together are not useful after this surgery. In addition, the insertion points of these muscles are the bony prominences that are required to be denuded to allow fusion to take place in the posterolateral position. Again- these claims of “minimally invasive” preserving the muscles do not make sense.

Any surgery is “open surgery”. It just depends upon where you make the incision (or incisions). Now- I don’t want to dissuade you from a surgeon who does “minimally invasive” surgery as if he or she is great at this technique, you should be well served. I will say that 40% of my practice is revision surgery to correct failed surgeries performed at other institutions. I see more failures of fusion requiring revisions of TLIFs performed from the “minimally invasive” side than the mini open or MIMS technique.

Most likely, you would need a decompression of the foramen as the collapse of the disc height along with the slip and bone spur formation that typically accompanies this disorder produces foraminal stenosis.

The most important question you ask is how to pick a good spine surgeon and I do not have an answer for that yet. There are nationally “unknown” surgeons who are excellent and some national figures that are less than excellent. Even I am somewhat stumped by that question. The internet has helped somewhat to make some of the research efforts easier but there is much false information on the internet. I wrote an article on my website regarding questions to ask a prospective spine surgeon about two years ago. Search my website for those questions.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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