prev acdf and ADR now pain is worse

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hohman1118
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April 23, 2015 at 4:10 pm

Post count: 8

#19119

I had a ct myelogram done and cannot see neurosurgery for several months due to them being backlogged at the Veterans Hospital. Can you please decipher this for me? I had an acdf at 3-4, 4-5 and the disc replacement on 5-6. I have more intense neck pain and right arm numbness and the area near my shoulder is almost unbearable despite many treatments. Acupuncture, TENS, PT, nerve blocks, and various meds.
FINDINGS:
Cervical:
Alignment: Anterior plate and screw fixation of C4-C5 and C3
vertebral body screw without loosening or hardware failure.
Intervertebral C2-3 and C5-C6 disc replacement noted.
Vertebrae: No fractures or destructive changes.
HOHMAN, DANA SUE CONFIDENTIAL Page 4 of 15
There is congenital cervical canal stenosis at all levels, with
level by level detailed analysis as follows:
Craniocervical junction: Normal
C2-3: Unremarkable. Congenital narrowing..
C3-4: Uncovertebral osteophytosis results in mild left neural
foraminal stenosis.Congenital narrowing.
C4-5: Near-total osseous fusion across the disc space without
foraminal stenosis. Congenital canal narrowing.
C5-6: Facet arthropathy and uncovertebral osteophytosis results
in mild right neural foraminal stenosis. Streak artifact from
intervertebral disc device limits evaluation of spinal canal at
this level, however, likely mild (congenital) canal stenosis.
C6-7: Right eccentric disc bulge without osseous foraminal
narrowing. Congenital canal narrowing.
C7-T1: Unremarkable.
Posterior fossa: Visualized portions are unremarkable.
Paraspinal soft tissues: No masses or swelling of the
visualized portions.
Thoracic:
Alignment: Normal.
Vertebrae: No fractures or destructive changes.
Multilevel degenerative changes without canal or foraminal
stenosis. Left eccentric protrusion at T1-T2 contacts the
anterior spinal cord without cord deformity.
Paraspinal soft tissues: Calcified mediastinal lymphadenopathy
and calcified granulomas throughout the lungs, otherwise
unremarkable.
Impression:
1. Successful lumbar puncture and intrathecal contrast
instillation without apparent complication.
2. Postsurgical changes of ACDF and disc replacements as
described. Multilevel degenerative changes of the cervical spine,
most prominent at C5-6, resulting in moderate to severe spinal
canal stenosis and neural foraminal stenoses as above. This is
superimposed on mild congenital spinal canal narrowing in the
cervical canal.
3. Focal small left paracentral disc protrusion at T1-T2 contacts
the left hemicord and causes associated mild spinal canal
stenosis. No other significant neural stenosis in the thoracic
spine.

Donald Corenman, MD, DC
Moderator

April 26, 2015 at 8:55 am

Post count: 8660

#19227

I am a little confused as to your report. You note an ACDF at C3-5 and an ADR (artificial disc replacement) at C5-6. However, your radiologist noted “Intervertebral C2-3 and C5-C6 disc replacement noted”. Was he correct or wrong about this reading? Has the C2-3 level been untouched surgically?

Your symptoms are not described well. Why did you have the surgeries in the first place? Was it for stenosis (narrowing of the canal with spinal cord compression), foraminal narrowing (nerve compression in the exit hole in the spine) or for local neck pain due to disc or facet degeneration?

Please read the section on how to describe symptoms to fully convey what pain you have and how it manifests.

Diagnosis will probably rest upon careful interpretation of your images, diagnostic nerve and facet blocks.Possible discograms can also be a helpful tool.

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.

hohman1118
Participant

April 26, 2015 at 5:51 pm

Post count: 8

#19237

I absolutely see what you are saying. C 2-3 was not touched. Error on dictation perhaps.
This was the discharge summary in 2013.
PRINCIPAL DIAGNOSIS:
Cervical stenosis.
C3-4 herniated nucleus pulposus.
C5-6 herniated nucleus pulposus.
PROCEDURES PERFORMED AT THIS HOSPITAL DURING CURRENT ADMISSION:
February 14 2013 ACDF at C3-C4 using a Globus Coalition System.
C5-6 cervical diskectomy and arthroplasty

SUMMARY:
Pt is a 43 y/o woman who as a result of a mva had a cervical fracture in 2001.
Pt underwent an ACDF at C4-C5. She did ok post operatively but has had
progressive neck pain which has become intense in 3 years. Pt reports that the
pain is 6/10 currently at worse it is a 10/10. The radiates down posterior of
neck to both shoulder blades. She has numbness up the back of her head and
numbness down the medial aspect of her right arm.

The following is from my physical therapy consult:
SUBJECTIVE
Date of injury: 2/14/13 C/S surgery
Mechanism of injury: 2000 MVA
Pain Scale and Quality: 8/10 currently and is an average pain number
Location of symptoms: headaches daily-global (“all over”), right-sided low back
pain, right UT area
Frequency of symptoms: loss of balance at random (~1x/week but may be d/t
decreased activity and decreased walking), incontinence in bladder increased
over past year (is now daily); headaches and neck pain daily
Aggravating Factors: prolonged sitting, walking, difficulty sleeping (6-hours on
a good night), using the computer.
OBJECTIVE
Imaging: 2-2-15 MRI C/S:
C6-C7 disc herniation to the right is noted with some cord
contact and flattening slightly progressed from the comparison
study. Radiologist recommends CT myelogram.
ASSESSMENT:
Ms. Hohman is a 45 year old female who presents to Physical Therapy today s/p
C3-5 fusion and C5-6 disc replacement in 2000 and 2013. She states her pain is
worse post-operatively than before and she is having difficulty managing it
currently. She has been utilizing taping methods provided by previous PT (this
is helpful) as well as attempting a rowing exercise but states that is painful.
Her activity consists of seated exercises with her 4-year old daughter (“baby
fist”) and 1x/week group water aerobics.
Today, Ms. Hohman presents with limited AROM in all planes of motion. Her
strength is decreased 2/2 decreased use and pain response. She presents holding
her head in her hands (chin in hands) 2/2 difficulty maintaining an upright
posture.

CT MYELOGRAM april 2015:
There is congenital cervical canal stenosis at all levels, with level by level detailed analysis as follows:
Craniocervical junction: Normal
C2-3: Unremarkable. Congenital narrowing..
C3-4: Uncovertebral osteophytosis results in mild left neural foraminal stenosis.Congenital narrowing.
C4-5: Near-total osseous fusion across the disc space without foraminal stenosis. Congenital canal narrowing.
C5-6: Facet arthropathy and uncovertebral osteophytosis results in mild right neural foraminal stenosis. Streak artifact from intervertebral disc device limits evaluation of spinal canal at this level, however, likely mild (congenital) canal stenosis.
C6-7: Right eccentric disc bulge without osseous foraminal narrowing. Congenital canal narrowing.
C7-T1: Unremarkable.

CT MYELOGRAM IMPRESSION:
Impression:
1. Successful lumbar puncture and intrathecal contrast
instillation without apparent complication.
2. Postsurgical changes of ACDF and disc replacements as
described. Multilevel degenerative changes of the cervical spine,
most prominent at C5-6, resulting in moderate to severe spinal
canal stenosis and neural foraminal stenoses as above. This is
superimposed on mild congenital spinal canal narrowing in the
cervical canal.
3. Focal small left paracentral disc protrusion at T1-T2 contacts
the left hemicord and causes associated mild spinal canal
stenosis. No other significant neural stenosis in the thoracic
spine.
I would just like to know in your opinion, what does this myelogram say and why is my neck pain worse especially in the muscle area of my right shoulder blade? I do have weakness, numbness, neck stiffness, sensations of pins and needles and tingling in my arms and hands.
Thank you!!

Donald Corenman, MD, DC
Moderator

April 26, 2015 at 9:05 pm

Post count: 8660

#19240

Your symptoms do not seem to be from nerve compression (arm pain, numbness, “pins and needles” and weakness in a dermatomal distribution)-see website under “symptoms of cervical nerve injuries”. Neither do your symptoms see to be derived from cord compression (see cervical stenosis and myelopathy_

Your symptoms are of central neck pain that radiates down to the shoulders. This pain can be derived from degenerative discs or degenerative facets (although nerve compression from the C3-4 level can also cause this type of pain).

The C5-6 disc replacement is a question I have. I generally do not like to use disc replacements with neck pain as the general complaint. It is true that the painful disc is replaced but the degenerative facets are actually more mobilized (more motion) which can increase pain if the facets contribute to pain generation.

Your next step is a pain workup. I would start with facet blocks (see this topic on the website with pain diary). Relief might make you a candidate for rhizotomies (again-website). You also might need discograms to look for discal pain generators.

Good luck!

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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Donald Corenman, MD, DC

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Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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