Revision after hybrid procedure with pseudoarthrosis

Tagged: revising a cervical pseudoarthrosis and artificial disc replacement

Viewing 5 posts - 1 through 5 (of 5 total)

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jdm
Participant

December 14, 2017 at 12:02 pm

Post count: 3

#27046

Dr. Corenman,

I am a 55 year old male in good health. In May, 2016 I underwent a fusion (C6-7) with arthroplasty (C5-6). For the fusion, the surgeon used a PEEK cage with allograft. Prior to surgery, i had no radicular pain (only axial). That pain improved but never fully resolved.

Today, I still have axial pain that is primarily a hard aching and sometimes burning. I am very active, and even play golf 2 or 3 times a week. Yet my neck always hurts. I have a desk job, and sitting or driving for long periods of time are the worst.

My X-ray and CT images show pseudoarthrosis. The artificial disc looks good. My surgeon believes that the pain is likely coming from the non-union. He gave me 3 options:

1. Do nothing
2. Take out the artificial disc and fuse both levels using autograft from my hip
3. Leave the disc and try refusing C6/7 with an autograft.

He stressed that option 3 might lead to a third surgery to fuse C5/6 if the pain does not resolve, but he felt it might be worth that risk to spare the artificial disc.

I am scheduled for revision surgery on 12/22 to do option 3. Here are my questions:

1. Since I am able to be active, it is crazy to have revision surgery? Prior to my first surgery, I was on pain meds and the pain was worse than it is now. I am presently on no pain meds. But I’m tired of having this constant pain, even though it is not as severe. I constantly think about it.

2. What is your opinion of only revising C6/7 and leaving the artificial disc at this time?

3. I am terrified of the autograft because of horror stories that I’ve read. What is your opinion as to whether I should opt for autograft or allograft?

4. How long do your patients wait before they resume golf?

Thanks very much for your advice.

Donald Corenman, MD, DC
Moderator

December 16, 2017 at 10:16 pm

Post count: 8660

#27068

First, you could undergo facet blocks at C5-6 to look for pain reduction. In patients with neck pain, artificial discs (ADR) could increase facet motion that leads to pain. A facet block with good relief of pain would indicate that the C5-6 level is a pain generator and this might lead to a decision to include this level in a fusion. (see; https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections-neck/). Conversely, no significant short term relief would lead to the conclusion that this level is not a pain generator and can be left alone. That is, if the ADR looks “OK” (no recession into bone, good alignment, retained lordosis and good motion on flexion/extension X-rays).

C6-7 probably needs to be addressed surgically. I would advise using your own iliac crest (ICBG) as a graft. I have performed this surgery in approximately 2500 levels and 96% have been iliac crest autograft (your own bone). I once did a study of 160 patients with this ICBG and only 3% had pain in their graft site after 6 weeks and only 2% long term (greater than 6 months) and this pain level was 2/10 for a O-10 visual pain scale.

I cannot comment on whether you need surgery or not as I can’t live with you to see how pain affects your behavior. I would rate pain that’s “I’m tired of having this constant pain, even though it is not as severe. I constantly think about it” as about 5-6/10 with I feel is surgical level pain.

I allow golf 4 weeks after fusion is solid (which takes about 6 weeks).

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.

jdm
Participant

December 17, 2017 at 5:47 am

Post count: 3

#27074

Thank you for your helpful response. I have had 3 facet injections in the past few months. Unfortunately, these were all multilevel (and not the single level diagnostic procedure that you outlined in the article). I had no short term relief (i.e., first 3 hours) from any of them. I did get some long term relief from the second (about 6 weeks with moderate to good pain control). I also had a radiofrequency ablation with no relief.

My surgeon said that my flexion/extension X-rays indicate that there may be some facet motion at the fused level (C6-7) caused by the non-union. Like you, he also raised the possibility that the pain could be coming from C5-6 due to too much facet motion at that level. However, he indicated that the ADR appears to be in proper position and functioning well.

With all that said, do you feel that my lack of short term pain relieve from the multilevel facet injections rules out a problem with the C5-6 facets, and would suggest simply revising C6-7 with an ICBG?

Thanks again.

Donald Corenman, MD, DC
Moderator

December 17, 2017 at 9:39 am

Post count: 8660

#27079

If you received no short term relief from the facet injections, then that reasonably rules out the facets as the cause of your pain. The ADR could still be a source of pain but more likely, it is the pseudoarthrosis that is the cause of most of your pain.

So, the most likely problem is the C6-7 level and that needs to be addressed. There still is the possibility that the C5-6 level can cause some of your current pain. You have to make a choice of just addressing the C6-7 level or doing both and converting the ADR to a fusion. I think that the ADR at most would be causing 30% of your total pain (and maybe no pain at all).

If you were OK with a 70% reduction of your pain as a result, then only address C6-7. If you think that might not be enough relief, I would then address both levels surgically.

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.

jdm
Participant

December 17, 2017 at 10:24 am

Post count: 3

#27082

That makes perfect sense. The reason for the ADR was to reduce the likelihood of ASD at C4-5. I’d like to keep the Mobi-C disc if possible. I think I’ll take my chances with just addressing C6-7. I can definitely live with 70% pain reduction, and if I get 100% that would be wonderful. Again, thank you for your assistance in making this decision.
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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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