Upper lumbar chronic pain (Suspected Annular tear) (Clear MRI/Xray)

Tagged: Annular tear athlete painful discogenic pain thoracolumbar junction l1-l2

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Total2k
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September 3, 2020 at 9:23 am

Post count: 2

#32942

Hi Dr Corenman, I’ve been a long time lurker of this website thank you for all of the resources and information.

I’m an athletic 20-year-old male, I compete in BMX and I also run, surf and golf.
That being said 4 months ago, while riding my bike, I noticed my back was hurting more than normal, I tried to ride through the pain until it gradually became too painful to continue. I didn’t think much of it at the time, until days went by and I realized it wasn’t recovering.
I’ve had on and off pain in my spine everyday since then, I’ve seen 2 back specialists who couldn’t provide a diagnosis or treatment plan. I’ve tried physical therapy with no improvement. I received an mri and xray that showed everything as normal and healthy.

Pain location and type:
Deep, dull, weak, ache in my upper lumbar spine that is worsened by actvity. Its central to my spine, although sometimes slightly worse on the right side. Its near my thoracolumbar junction, around L1-L2-L3 levels. Pain is never below L3.
Characteristics are very much discogenic with no pain in any of my surrounding muscles.
Spine feels fatigued, weak and unstable at the painful levels of l1-l2-l3.
Very sensitive to slight forward flexion or weight away from my center of gravity.
No pain with extension or side bending.

On the VAS 1/10 scale:
1 while resting
3 overall throughout the day while resting
5 if irritated throughout the day
7 with sports

Pain triggers
While resting I’m aware of the dull ache but its very mild, almost non-existant. The pain is made much worse with slumping, forward flexion or any forward bend away from my center of gravity. Sitting with no lumbar support also irritates it.
There isn’t one specific trigger for sharp pain, instead of the pain accumulates throughout the day, becoming more irritated and painful when I stress my spine. I can swim and walk for hours with no pain, but running, jumping, picking things up off the floor, brushing my teeth, sitting at a dinner table, all of these will progressively worsen the pain throughout the day. Sports like BMX, surfing, golfing are unbearable and will leave me in pain for a few days. I’ve stopped all athletics since the injury with no progress in my recovery.
Sneezing is very painful.

I received my MRI results expecting to find an upper lumbar disc herniation or an annular tear but I was surprised that my doctor found nothing. My Xrays also showing no abnormalities.
My MRI says: “The thecal sac has a normal diameter. No evidence of disc bulge or protrusion. The neural foramina are patent bilaterally” for every level of my spine.

So at this point I’m out of options for diagnosis or treatment. I’m at the point of just waiting hoping it’ll go away. Its been hurting for 4 months with mild improvement but many many setbacks on a day-to-day basis. Simple activities will re-irritate my spine right as I imagine its improving.

Personal suspected diagnosis
I found through the internet that some annular tears won’t show on an MRI, and that while most are asymptomatic, some can be very painful and toxic. With my pain characteristics being discogenic in nature (pain with forward flexion, sneezing, and sitting, sports), this leaves me to believe the only possibility is I have a toxic annular tear that was missed by the MRI.

That being said I’m still left not knowing what my official diagnosis is, what my timeline for recovery looks like, or what I should expect for the future.
I could find very little information on painful annular tears, especially in the upper lumbar region. I also heard that unlike disc herniations, where the pain-producing Nucleus Pulposule can retract and heal, a painful annular tear can take years to heal the outer layer, and will leave weak scar tissue that may hold me back from ever being athletic again. The inner layers, if painful, might never heal.
My pain hasn’t improved in 4 months and I’m very depressed and anxious that this will affect the rest of my life. I’m very young and still want to work as a fight fighter and train as a BMX athlete.

So I guess my questions are:
1. Do painful annular tears ever fully recover in athletes?
2. Could there be any other diagnostic explanation for my pain and clear MRI’s
3. Could my young age play a role in the speed of the recovery of my disc?
4. Is there any research on the timeline and effective recovery of annular tears
I’d also just appreciate any other perspective on my case

Thank you for your consideration,
Alex

Donald Corenman, MD, DC
Moderator

September 3, 2020 at 1:55 pm

Post count: 8660

#32945

“I’ve had on and off pain in my spine everyday… VAS 1/10 scale: 7 with sports… Sports like BMX, surfing, golfing are unbearable and will leave me in pain for a few days”.

“I received an mri and xray that showed everything as normal and healthy…some annular tears won’t show on an MRI…can be very painful and toxic”.

There are disorders that are not mechanical (no obvious structural derangement on MRI) such as metabolic and rheumatological disorders. See https://neckandback.com/conditions/rheumatological-conditions-affect-spine/.

There are disorders that can be missed by a radiologist such as https://neckandback.com/conditions/thoraco-lumbar-scheuermanns-disorder/ and https://neckandback.com/conditions/spondylolysis-in-children-healing-potential-and-treatment-pars-interarticularis-fractures-in-the-lumbar-spine-in-adolescents/ (not just in kids).

See if any of those might fit. It is highly unlikely that you have a missed annular tear.

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.

Total2k
Participant

September 4, 2020 at 7:43 am

Post count: 2

#32956

Thanks for the reply,
I’ve seen at most of these disorders when I was originally trying to find a diagnosis and I think I can rule most of them out based on symptoms and imaging.
Autoimmune disorders: I have no morning stiffness and no pain improvement with exercise. My imaging shows no fusion, bone spurs, abnormalities, or sights of inflammation
Degenerative Disc Disease: I show no fluid loss or disc height loss. Imaging shows very healthy discs.
Spondylolysis and pars fracture: This was actually my initial guess, but I’ve begun to have more doubts. I have pain with weighted forward flexion, but I can side bend and extend backwards to my end range with no pain. If the pain was from facet or pars then I think I should be able to trigger pain by grinding and pressuring my spine by going into extension. I also have no pain from any palpation. Additionally, I’ve also had Xrays and Mri’s so if it were a fracture or a sight of inflammation its most likely shown up. I also show no signs of slippage or instability, although my imaging was taken while lying down. Can early instability be missed if the imaging wasn’t taken in a flexed or weighted position? I would love your input on this because I couldn’t find much information on fractures that only trigger pain with flexion, instead of extension.
Thoraco-Lumbar Scheuermann’s Disorder: This was very interesting for me to read, and was the one condition I hadn’t considered previously. According to my imaging, I have a normal curvature with no humpback, no schorls nodes, no “visible” endplate fractures, no noticeable wedging vertebrae. Could an early stage of this disorder not be visible on imaging? Like an annular tear, could I have endplate damage that isn’t visible on an MRI?

All that being said, these are all reasons that I’ve self-diagnosis an annular tear. All of these other disorders have symptoms that I can’t fully relate too.
An annular tear is the only diagnosis I’ve found that matches my symptoms to a tee.
Although I’ve heard it’s a controversial diagnosis because most cases are asymptomatic, I don’t know what options I have left considering I have a clear MRI but my pain symptoms seem very discogenic.
This still leaves me with my previous questions

I really appreciate your consideration,
Thank you,
Alex

Donald Corenman, MD, DC
Moderator

September 4, 2020 at 10:24 am

Post count: 8660

#32957

Annular tears are generally visible on an MRI. An occult tear would be highly unlikely and even more unlikely at higher levels (L1-3) or thoracolumbar levels. There are conditions that cause local pain (myofascial pain syndromes) and conditions that mimic thoracolumbar pain such as visceral (organ specific like gall bladder) referral pain. If there are no endplate changes, no evidence of fracture such as pars or facet fractures, no malalignment issues or discal injuries and no tumors, this might be an unusual presentation of a myofascial pain syndrome. Make sure this is not referral pain from a higher spinal disorder like a thoracic disc herniation.

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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