Extending a fused level of the lumbar spine into adjacent levels

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Jellyhall
Participant

August 13, 2020 at 4:33 pm

Post count: 91

#32840

Dr Corenman, I want to thank you for giving your time and answering our questions about our spines.
I have problems throughout my spine and have already had a cervical ACDF of C3/4/5 eight and a half years ago, and a lumbar fusion of L4/5 which was ten and a half years ago.

I am now suffering with adjacent levels causing pain, but today I want to ask you aboout my lumbar spine.
I now have herniated discs at L2/3, L3/4 and L5/S1 which are causing me pain.
Surgery was mentioned about three and a half years ago, on L2/3 and L3/4, which he said would need to be fused and the L4/5 fusion would have to be extended into them. He said it would be very invasive.
The last neurosurgeon I spoke to a week ago said that to do surgery on those levels, it would be very difficult to remove the hardware. I assume she meant the rods to put in longer rods. She referred to how long ago my surgery was and I think she was saying that it would now be difficult to get them out because of bone grown over them.

I do hear of people having fusion surgery on adjacent levels to an existing fusion, so it must be possible. Does the fact that my surgery was over ten years ago make this more difficult.
I am also wondering about fusing L2/3/4 and L5/S1 and joining them into the already fused level of L4/5.

I am also concerned that L1/T12 has a herniated disc and has developed a degenerative spondylolissthesis (retrolisthesis) which is beginning to change the curve of my spine. There are herniated discs at L7/8, L8/9, L9/10 and L10/11. There is also a retrolisthesis developing at L2/3 and another at C2/3. Is there anything I can do to stop or slow down the progression of these slips?

Donald Corenman, MD, DC
Moderator

October 8, 2021 at 7:03 pm

Post count: 8660

#34517

It is distinctly not a problem to get old hardware out. When I found it necessary to remove hardware, I had about a 99% success rate and if one or two screws cannot come out, you can easily bypass them. If you have multiple levels and most need TLIF fusion (which you cannot do at cord level (L1-2 generally), you can do anterior-lateral OLIF and posterior fusion. You do have to be careful in that you have degenerative levels already above your T12-L1 level and these can wear out more quickly if already degenerative. You also cannot stop a fusion at the apex of a curve (T7-8).

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.

Jellyhall
Participant

November 1, 2021 at 1:15 pm

Post count: 91

#34571

Thank you for your reply Dr Corenman.
I have now had a telephone appointment with another of the registrars of the consultant that I am under. I deal with a different one at each appointment, so neveer know how much of my file they have read and there isn’t time to go through everything during the appointment, which is 15 minutes long, because we are talking about the whole of my spine.

This latest neurosurgeon said again, several times, that doing surgery on my spine would be “extensively complicated and invasive”. He also said that “any surgical intervention on my spine would be associated with significant morbidity and would not guarantee reversal of symptoms and could make them worse. In fact, there is no surgical target for the back pain.” He said it would be a last resort and is sending me to Pain Management to try spinal injections. I was referred for this in August 2019, but by the time my name got to the top of the list, I had one appointment but the Covid shutdown happened, so I never moved on to have the Medial Branch Block injections he wanted to do to check which levels were pain generators before doing Radiofrequency Ablation there. I am still waiting to receive a reply to a letter I have sent asking to move forward with my treatment.

I now have numbness in the little finger and half the ring finger on my left hand, that doesn’t go away. Sometimes it is worse than others, but it never completely goes away. The neurosurgeon said he wasn’t worried about this because the EMG/nerve tests I had done a year ago didn’t show any evidence of left ulnar neuropathy. I hope he is right. My Mri report done in November 2019 states there is right exit foraminal narrowing at C4/5 and C5/6 and minimal left exit foraminal narrowing at C6/7.Flexion and extension cervical x-rays done in November 2019 showed a grade 1 anterolisthesis of C2 on C3 which reduces slightly on extension.

The MRI report from November 2019 mentions there are small disc osteophytes (?) in the mid and lower thoracic spine as noted previously in 2018. These are at T12/L1, T8/9, T9/10 and at T2/3.
It also says there is straightening of the lumbar spine and minimal retrolisthesis at L2/3. It also says there are disc-osteophytes noted at L2/3, L3/4 and L5/S1 levels.
I asked him if the straightening of my lumbar spine was going to be a problem because I suppose the spine isn’t loaded correctly now. He said yes it would and that it would be part of the reason I was in pain.

He also mentions that my MRI scan done in November 2019 showed acute effusion in both cervical and lumbar previously operated sigments. Also that there is extensive degenerative spine disease along the whole spine.
They will have another telephone appointment with me in 12 months time.

Dr Corenman, I would be extremely grateful if you could comment on this, especially the points that I have put in bold. I know that there is a lot here, sorry.

Donald Corenman, MD, DC
Moderator

November 1, 2021 at 1:35 pm

Post count: 8660

#34572

Adjacent segment disease is a real pain generator but doesn’t necessarily mean that your pain generators are the adjacent levels. A work-up would need to be completed to determine that. Nonetheless, your consult surgeon sounds like he would not be interested in pursuing surgery. If you have not yet gone thru MBB and RFA, that should be the next step before surgery is considered.

For your neck, your complaint of “I now have numbness in the little finger and half the ring finger on my left hand, that doesn’t go away” could be the ulnar nerve at the Cubital tunnel, the C8 nerve root, Tunnel of Guyon compression or even thoracic outlet syndrome. The EMG/NCV and a thorough physical examination can determine that.

See:
https://neckandback.com/conditions/cubital-tunnel-syndrome/
https://neckandback.com/conditions/thoracic-outlet-syndrome/
https://neckandback.com/conditions/symptoms-of-cervical-nerve-injuries/

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.

Donald Corenman, MD, DC
Moderator

November 1, 2021 at 1:35 pm

Post count: 8660

#34573

Adjacent segment disease is a real pain generator but doesn’t necessarily mean that your pain generators are the adjacent levels. A work-up would need to be completed to determine that. Nonetheless, your consult surgeon sounds like he would not be interested in pursuing surgery. If you have not yet gone thru MBB and RFA, that should be the next step before surgery is considered.

For your neck, your complaint of “I now have numbness in the little finger and half the ring finger on my left hand, that doesn’t go away” could be the ulnar nerve at the Cubital tunnel, the C8 nerve root, Tunnel of Guyon compression or even thoracic outlet syndrome. The EMG/NCV and a thorough physical examination can determine that.

See:
https://neckandback.com/conditions/cubital-tunnel-syndrome/
https://neckandback.com/conditions/thoracic-outlet-syndrome/
https://neckandback.com/conditions/symptoms-of-cervical-nerve-injuries/

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.

Jellyhall
Participant

November 2, 2021 at 12:19 pm

Post count: 91

#34577

Thank you for your reply Dr Corenamn.

I am waiting to see the Pain Management Consultant, but here in the UK the wait is generally long.

My MRI scan done in November 2019 showed acute effusion in both cervical and lumbar previously operated segments. Also that there is extensive degenerative spine disease along the whole spine.

Could you pleases explain what ‘acute effusion in both cervical and lumbar previously operated segments’ means?

My next appointment is in September 2022 and will be another telephone appointment, so it won’t be possible to have a thorough physical examination.
I suspect that the neurosurgeons will leave me until I need to have surgery urgently, as there is such a long list and backlog due to Covid stopping elective surgeries.
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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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