Failed ACDF?? Next steps

Tagged: ACDF, CRPS, Nerve pain, radiculopathy

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cgklein
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February 13, 2017 at 4:00 pm

Post count: 7

#24327

A bit of history is warranted. I had ACDF surgery on February 4th, 2016 at the age of 52. ACDF was performed on C4-C5 and C5-C6 with PEEK interbody graft filled with local autograft and allograft. The reason for the surgery was instability at C4-C5 and C5-6 along with moderately severe forminal stenosis and degerative disc disease. I had tingling and numbness in my left hand and moderate to severe pain in my left shoulder and upper arm.

Throughout my recovery, I have continued moderate to severe pain in my left shoulder. A few months ago the shoulder and arm pain started in my right arm along with numbness in my right thumb and index finger. The pain switches from left to right side during the day but is never together.

In June I moved to AZ and have continued to be in touch with my neurosurgeon. I last saw him in September 2016. In July, I found out that I have osteoporosis and vitamin D3 deficiency. I am taking Prolia and Vitamin D3 pills to address this. This was not known prior to surgery. In addition, I have CRPS in my left lower limb (diagnosed in 2012). I have a Medtronic SCS implant (paddle leads) which was “installed” in 2015 by the same neurosurgeon.

I recently had a nerve conduction study performed with the following results, “Nerve conduction studies of the upper extremities are normal bilaterally. Electromyography of the left upper extremity show reinnervation changes in the C6 distribution. Study is consistent with a chronic C6 radiculopathy of the left upper extremity.” They did not perform a Electromyography of my right arm even though I requested it.

I am taking Gabapentin for the nerve pain, which helps some as well as Percocet. I am tired of this pain and have waited the year for fusion. Sometimes that pain is better lying down sometimes it makes it worse.

My neurosurgeon says that my nerve healing could take 12-18 months (email) but has not made any specific recommendations on next steps even though I have asked.

My question is, what should I do now? I know that it is possible that I have permanent nerve damage but it seems really weird that the pain moves from left to right side and back. Do I wait longer, see a neurosurgeon or a neurologist or ???

Your thoughts are appreciated, CK

Donald Corenman, MD, DC
Moderator

February 13, 2017 at 5:12 pm

Post count: 8660

#24328

Unfortunately, EMGs are not very effective for understanding nerve pain origin as pain nerves are too small to be tested with the EMG. I would suspect that you might have one of three problems; a failed fusion (pseudooarthrosis), continued nerve compression in spite of solid fusion or chronic radiculopathy. A new MRI and a new CT scan would be very helpful to start your diagnostic workup.

Also, a spine surgeon would be a good sext step (an orthopaedist like me who specializes in spine) as we have more experience in revision work.

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.

cgklein
Participant

February 13, 2017 at 6:39 pm

Post count: 7

#24329

Dr. Corenman, thank you for your response. I will find a spine surgeon and follow-up with a CT scan or MRI. If my issue is a failed fusion, how does my osteoporosis and/or CRPS affect my ability to have a successful fusion in the future? Since it has been over a year since my ACDF surgery and the x-ray shows that the fusion is not complete, would this indicate a failed fusion or could it take longer than a year to fuse?

Thank you, CK

Donald Corenman, MD, DC
Moderator

February 14, 2017 at 1:22 am

Post count: 8660

#24330

After one year, if you have a pseudoarthrosis, it is highly unlikely it will heal in the future. CRPS will not inhibit healing but Vit.D insufficiency however will impair healing. Osteoporosis generally does not inhibit healing but will allow the grafts to subside into the vertebral bodies in some cases.

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.

cgklein
Participant

February 16, 2017 at 2:58 pm

Post count: 7

#24342

Dr. Corenman, thank you again. Two follow-up questions. First, since it appears that I have pseudoarthrosis and I know that I have a pinched C6 nerve, is it okay to use my home traction device or would this potentially cause additional damage to the pseudoarthrosis? Second, during the past year during my recovery of my ACDF, I used Voltaren Gel on my shoulder. Could this have impacted by fusion?

Thanks you, CK

Donald Corenman, MD, DC
Moderator

February 16, 2017 at 3:28 pm

Post count: 8660

#24343

Traction in the face of a pseudoarthrosis is OK. Voltaren is a non-steroidal anti-inflammatory and as such, can affect the fusion in the first two to three months.

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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81 reviews

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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