Direct Pars Repair with SBO and Transitional S1

Tagged: Unilateral pars fracture with normal disc

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Seeker99
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February 12, 2018 at 1:17 pm

Post count: 1

#27535

Good day Dr. Corenman,
Thank you for this forum and the work you do. My son is a freshman in a well-regarded College soccer program. He is determined to continue playing. His coaches feel he has the qualities to go much higher.

May 2016 – developed increasing lower back/hip pain, was prescribed anti-inflammatories, rest and physio.

July 8/16 – X-Ray – AP and lateral views (due to age). Lumbarization of the 1st sacral segment. Spina Bifida Occulta S1. No spondylolisthesis on lateral.

July 25/16 MRI #1 – MRI – 6 lumbar type vertebrae are noted, with a transitional L6 vertebra present with sacrilization of its left transverse process and associated pseudoarthrosis. At the L5-L6 level mild stress reaction may be present in the pars interarticularis bilaterally, but no definite spondylolytic defect is seen. Mild bony hypertrophy of the posterior facet joints is noted but no foraminal stenosis can be demonstrated. A tiny 0.7 X 0.6 X 0.3 cm synovial cyst appears to be present along the inferior aspect of the left posterior facet joint, outside the spinal canal consistent with degenerative changes in both posterior facet joints. At the L6-S1 level a more rudimentary disc is noted. No disc herniation or foraminal stenosis can be demonstrated.

November 2016 – Rest and recover with physio and gradually increasing activity. Returned to team training in mid-November and regained match fitness by January 2017. A couple stops and starts as he/his body adjusted to the increasing workload

Dec 1/16 MRI #2 – routine non-enhanced. Clinical – to rule out spondylolisthesis. There is lumbarization of the S1 segment. The thecal sac remains widely patent throughout the lumbar spine the conus lies normally at the L1 level. There is no evidence of significant spinal dysraphism. There is no disc herniation or canal stenosis. Marrow signal and bony alignment are normal and there is no evidence of spondylolysis spondylolisthesis.

Jan 25/17 MRI #3 – Normal signal. Lumbarization of the S1 segment. No significant facet joint arthropathic changes visible. There is hyperintensity along the pars interarticularis at the L5-S1 bilaterally suggestive of sclerosis with no evidence of spondylolisthesis. CT scan is more sensitive in detecting spondylolysis.

Progressive training and physical build-up from January 2017 to college pre-season camp August 2017, including trials and fitness testing.

August 17/17 – reoccurrence of progressive low back/hip pain, right side. Applied rest and physio without success.

Sept 28/17 CT Scan) – without contrast. Pars interarticularis defect on the left at L5, mild distraction at the site of the defect, margins well-corticated suggesting this is probably a chronic finding. It could, however, allow motion at the facet joint on the left at L5-S1, correlate clinically. There is no subluxation of L5 on S1

Based on the above can a direct pars repair be considered? Left or both sides? Does the lumbarization/Spina Bifida Occulta of the S1 contribute to the problem/symptoms and need to be addressed?

We truly appreciate your feedback.

Cheers

Donald Corenman, MD, DC
Moderator

February 18, 2018 at 2:34 pm

Post count: 8660

#27631

July 25/16 MRI #1: “lumbar type vertebrae are noted, with a transitional L6 vertebra present with sacrilization of its left transverse process and associated pseudoarthrosis. At the L6-S1 level a more rudimentary disc is noted”. This is a lumbarization of S1 where the first sacral segment tends to look like an L5 segment. Generally, these are asymptomatic.
“At the L5-L6 level mild stress reaction may be present in the pars interarticularis bilaterally, but no definite spondylolytic defect is seen”. This is an indication of potential pars fractures due to the increased stress in this level.

Dec 1/16 MRI #2: The radiologist does not comment specifically regarding the L5 pars. Maybe the stress reaction improved or maybe this area was overlooked when reading the films.

Jan 25/17 MRI #3: “is hyperintensity along the pars interarticularis at the L5-S1 bilaterally suggestive of sclerosis with no evidence of spondylolisthesis”. Generally, this sentence is unusual as a hyper-intensive signal indicates a bony stress reaction and sclerosis (increased bone deposition due to chronic stress) normally presents with a decreased signal. Maybe he dictated incorrectly. Nonetheless, there is reactivity of the pars indicating chronic stress.

Sept 28/17 CT Scan: “Pars interarticularis defect on the left at L5, mild distraction at the site of the defect, margins well-corticated suggesting this is probably a chronic finding”. This is now the test that helps to indicate the actual problem as there is a non-healing pars fracture on the left. The radiologist does not comment on the right side which could be sclerotic (under stress) due to taking the extra load since the left side is fractured.

This would generally require a pars repair. I thought that only the fractured side should be repaired but about one year ago I repaired a unilateral stress fracture with the other side being typically sclerotic. After the repaired side healed, the opposite side fractured with return to activity. This obviously indicates that the sclerotic bone is not normal in some cases (I had fixed unilateral fractures for years without having this occur) and I repair both sides now in a unilateral fracture.

The lumbarization does not affect the decision to repair the pars.

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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