how long to continue conservative treatment before surgery

Tagged: Old spondylolisthesis and new onset herniation with leg weakness

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sdb1956
Participant

March 12, 2018 at 8:23 am

Post count: 3

#27833

Dear Dr. Corenman,
I was active and healthy before I developed sudden onset, severe unilateral sciatica four months ago, after doing alot of heavy lifting and yard work. Before that I had no prior history of back problems. After three trips to the emergency room in November and not being able to walk, sit, or stand, I got referred to a neurosurgeon and had an MRI. The results showed some minimal bulging lumbar discs, a minimal grade 1 spondylothesis at l5/s1, and a small disc protrusion at l5/s1 which impinged the s1 nerve. So far, I have had numerous pain medications,3 epidural injections, and now over a month of physical therapy. Although my pain level has gone from severe and disabling, to moderate but still disabling, my legs are weak and I cannot sit or stand in one position for more than a few minutes before pain increases. In January, I was offered a microdiscectomy, but I was convinced to continue with conservative treatment because at that point I had improved from the initial severe symptoms. At this time I believe my improvement has plateaued, and the physical therapist is more focused on hip and muscle problems, than the bulging disc, in terms of getting me back to a functional state. I am concerned that I am not going to recover, and that I am still in significant pain, and surgery should be done, before I become more weak. How much can a disc bulge cause pain and disability, and how long should someone pursue conservative treatment before getting surgery? How long is too long to wait before nerve damage is permanent–6 months?
Susan

Donald Corenman, MD, DC
Moderator

March 15, 2018 at 8:48 am

Post count: 8660

#27859

Be careful as there are no “minimal” grade I spondylolisthesis. If you have motor weakness (found by a physical examination), then in my opinion, you need surgery. The problem is that a disc herniation associated with an isthmic spondylolisthesis (” minimal grade 1 spondylothesis at l5/s1, and a small disc protrusion at l5/s1 which impinged the s1 nerve”), is a problem to manage with a simple microdiscectomy. The instability from the pars fractures probably created the disc tear and the herniation in the first place. In my experience, disc herniations associated with an isthmic spondylolisthesis may need a fusion with the microdiscecomy. The reason is that disc failure with the slip tends to cause a much higher percentage of recurrent herniations and back pain. See https://neckandback.com/conditions/isthmic-spondylolisthesis-slipping-of-a-vertebra-because-of-fracture/ and
https://neckandback.com/conditions/herniated-disc-lumbar-spine/

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.

sdb1956
Participant

March 15, 2018 at 10:28 am

Post count: 3

#27863

Dr. Corenman,
Thank you for your response. I never experienced any back pain before this sciatica appeared in November, and I am 61 years old, and I don’t know if I always had pars defects and spondylolithesis. If the slip is old/stable is a discectomy possible to alleviate the sciatica problem? Should I have a bone scan or some other test to see how stable or unstable the situation is? After I had such a severe attack in November, and have had some improvement, but still in pain and weak, should I still give pt more time?
I am very afraid of jumping right into a fusion as the solution.
Susan

Donald Corenman, MD, DC
Moderator

March 18, 2018 at 5:13 am

Post count: 8660

#27892

You had the pars defects from the ages of 8-15 most likely. During this period, the pars fractured, you had a couple of weeks of back aching that eventually “went away” and you were able to live with the slip until the disc tore recently and you developed a herniation. If you are still exhibiting weakness, it is my opinion that you need at least a decompression of the nerve root. You don’t have to “jump into a fusion” but in my experience, the microdiscectomy will eventually lead to a fusion.

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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