Help with MRI

Tagged: diagnostic vs therapeutic injections, New opposite sided symptoms 3 months after a lumbar microdiscectomy

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wmiller
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December 2, 2019 at 4:09 pm

Post count: 30

#31609

Hello, Dr. Corneman. I’m going to paste below the findings of two MRIs. One was done in June, right before I had an urgent right L5/S1 discectomy, and the other was Nov. 14. Background

-I had complete resolution of symptoms after the surgery in June.
-In sept./October began having left-sided LBP that went down leg, mostly lateral. It is much worse with walking, better with sitting/bending forward. Walking for more than 10 minutes is nearly impossible due to pain in back/down leg and into ankle.
-I had PT for a month before an MRI was ordered. About four days AFTER the MRI, I began having identical, but less severe, symptoms on the right side–so I’m not sure this MRI is representative of those.
-I saw surgeon today, and he said that he didn’t see anything in my MRI that points to exactly where the pain is coming from (and while it’s not as bad as my herniation in June), it keeps me from living a normal life. He suspects there is a small reherniation affecting S1 that is not caught on MRI, but I have an EMG saying that L5 is what is the culprit. He says the MRI doesn’t indicate that L5 could be causing these symptoms, as the stenosis from the bulging disc is just “moderate” and I’m in significant pain. I had none of this pain when my June MRI was done. I’m pasting both MRIs for comparison (only the abnormal parts):

JUNE 2019 MRI:
L4-L5: There is mild, broad posterior bulging of the disc with a
small circumferential annular tear in the posterior disc margin. Mild
facet and ligamentum flavum hypertrophy are present. There is no
significant foraminal stenosis or mass effect on the exiting L4 nerve
roots. The L5 nerve roots are contacted in the lateral recesses but
do not appear compressed.

L5-S1: A large disc herniation arises from the midline and extends
into the right lateral recess, displacing and compressing the right
S1 nerve root. The herniated fragment measures approximately 1.8 cm
sagittal by 1.3 cm transverse by 0.8 cm AP. Mild disc bulging and
disc space narrowing results in mild bilateral foraminal stenosis but
the L5 nerve roots are not compressed.

NOVEMBER 2019 MRI:
L4-L5: There is shallow posterior bulging of the disc with mild
facet and ligamentum flavum hypertrophy. There is mild bilateral
foraminal encroachment and moderate lateral recess stenosis greater
on the left. The L5 nerve roots are contacted and the left L5 nerve
root may be slightly compressed.

L5-S1: There has been partial hemilaminotomy on the right. There is
enhancement in the surrounding soft tissues. There is a small amount
of fluid in the right facet joint. The herniated disc fragment noted
on the previous study has largely been resected. Mild posterior
bulging of the disc persists. There is mild bilateral foraminal
stenosis without evidence of nerve root impingement on either side.

Donald Corenman, MD, DC
Moderator

December 4, 2019 at 8:03 am

Post count: 8660

#31616

First you have to remember that I am looking at the MRI’s from the radiologist’s perspective so some information is lost.

In June, you had a large extruded HNP compressing the S1 root. That was obvious. In November, you had somewhat more significant left L4-5 lateral recess stenosis which would compress the left L5 nerve root. You do have “mild” foraminal stenosis bilaterally. This also could compress the left L5 root.

Your pain is stenotic in nature, worse with standing and better with bending (“It is much worse with walking, better with sitting/bending forward”). Stenotic pain is associated with both lateral recess stenosis and with foraminal stenosis which fits with both levels.

I would note that you probably could benefit from a small volume transforaminal epidural steroid injection at L4-5 left and then on a separate day, a selective nerve root block at L5-S1 left. Keep a pain diary to determine which level is more significantly involved.

See https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/
https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/
https://neckandback.com/treatments/diagnostic-vs-therapeutic-injections/

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.

wmiller
Participant

December 4, 2019 at 6:37 pm

Post count: 30

#31623

Thank you. I had my injections yesterday, and he did something similar to what you suggested. He first numbed S1 (no steroid). After about 2-4 minutes they had me try to walk around and see how it felt. The back pain was no better, and I could still elicit the leg pain. So then he did the same with L5. I had some reduction in the back pain (but not all) and complete resolution of the leg pain (even touching where I usually have the pain was completely numb). So he put a steroid at L5 on both sides. He feels sure it is L5 because of this and because my EMG indicates L5.

Is it normal for the injection of numbing medicine not to totally remove the back pain? He told me the remaining pain I was feeling there was from the disc itself, as he only injected at the nerve root. I am hoping that the steroids I had will calm not just the leg pain, but back pain also.

Donald Corenman, MD, DC
Moderator

December 5, 2019 at 5:38 am

Post count: 8660

#31630

Back pain generally is generated by disc and occasionally facet so epidurals might not yield full back pain relief. Leg pain is generally nerve root mediated so a block should give temporary relief as long as it is the correct nerve numbed.

Your L5 nerve seems to be the inflamed nerve but as I noted earlier, can be compressed at the L4-5 level in the lateral recess or the L5- S1 level at the foramen. The injection correctly identified the correct nerve (L5) but was not specific enough to identify the compressive location.

Steroids can sometimes allow long term relief of back pain.

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.

wmiller
Participant

December 5, 2019 at 11:07 pm

Post count: 30

#31651

Thanks. I’m not sure if he did both levels for L5. I sent a message to ask.

I am confused about surgical options (which I hope i don’t need) for foraminal and recess stenosis caused by a bulging, but not herniated, disc. A laminectomy to decompress would not get rid of the bulging disc, correct? So if it herniated I would get a discectomy (and they told me it’s very stretched and close to herniating, but trying to prevent), but if I cannot get sustained relief from injections and PT, how would stenosis be treated if the main cause was a bulging disc?

wmiller
Participant

December 6, 2019 at 3:42 pm

Post count: 30

#31657

wmiller wrote:

Thanks. I’m not sure if he did both levels for L5. I sent a message to ask.

I am confused about surgical options (which I hope i don’t need) for foraminal and recess stenosis caused by a bulging, but not herniated, disc. A laminectomy to decompress would not get rid of the bulging disc, correct? So if it herniated I would get a discectomy (and they told me it’s very stretched and close to herniating, but trying to prevent), but if I cannot get sustained relief from injections and PT, how would stenosis be treated if the main cause was a bulging disc?

As an update: they called me back and said he did L5/S1 only bilaterally and that the medicine would “move up and down levels.” I don’t understand how a trans foraminal injection can affect multiple levels at once. Is that even possible? I’ve had no relief after 4 days. If this continues, i should ask for an L4/L5 injection? At this point I’m ready to come to Vail!
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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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