Problems with Stenosis after successful L4/L5 Microdiscectomy

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BCalvert
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August 2, 2021 at 8:20 am

Post count: 4

#34234

Thank you for taking a look at this Dr. I had a successful 6mm herniation removal with an l4/l5 mirodiscectomy on 2/25/2020. All was good and I was making progress. At that time the MRI showed I also had 2mm bulges at l3/l4 and l5/s1.
A little over a year later. March or 2021 I started to have flare ups and pain again. First it was right side with pain in buttocks and down leg. Similiar to what I have felt in past. It comes and goes with no rhyme or reason it seams. I also have down left side as well but not consistently. This in in buttocks, but also down front of hip, thigh and to the knee. Also in groin slightly. I was given a second MRI for comparison with and without contrast. As well as xrays and this is what it said below. I am just comletely disheartened as to what to do. I assume I am going to just need to get used to life with pain. I see the Neurosurgeon in a 10 days to discuss the below findings. I have not been able to push myself with home PT and stengthening as I am/was afraid of making it worse. But it might be I got that all wrong. I am a healthy 5’7′ and 160 pound and up until this was very active in gym etc. Is there any hope for me here and what would you recommend as course of action? Epidural Injections?

I should add my pain levels are 3 on average with occational 5 at its worst right now. On days its a 1 or 2 I feel the weight of the world lifted off me. I have not taken a dose pak yet and have never been on any neurontins. I manage it fairly well with Ibuprofen and Tylenol, ice and rest if needed.

XRAY: Vertebral body heights are normal. There is intervertebral
disc space narrowing at L4-5. There is a minimal degree of perceived
retrolisthesis of L4 on L5 which remains fixed between flexion and
extension. No other significant spondylolisthesis is seen. Minimal
degree of anterior osteophyte formation seen at L3-4.

MRI FINDINGS:
Subtle dextroscoliosis of the lumbar spine is noted on the coronal
images. Slight straightening of normal lumbar lordosis is noted
suggestive of muscle spasm. Slight decreased disc height and hydration
is noted at the L3-4 and L4-5 levels. There is no focal marrow
replacement or marrow edema of the lumbar vertebrae. The conus
medullaris appears within normal limits terminating at the L1 level.
The presence of 5 lumbar vertebrae is presumed.

T12-L1: There is no central canal or foraminal stenosis. No
significant posterior disc protrusion is evident.

L1-2: There is no central canal or foraminal stenosis. No significant
posterior disc protrusion is evident.

L2-3: There is no central canal or foraminal stenosis. No significant
posterior disc protrusion is evident.

L3-4: There is a diffuse disc bulge of the annulus fibrosus measuring
approximately 2 mm AP dimension which encroaches upon the anterior
surface of the thecal sac. Central annular tear is again noted.
Together with facet joint degenerate changes, ligamentum flavum
hypertrophy and posterior epidural lipomatosis a minimal degree of
central canal stenosis is noted. No significant foraminal stenosis is
evident. Essentially stable appearance is noted at this level when
compared to prior study.

L4-5: Since previous examination there has been right hemilaminotomy
with discectomy. Previously noted right paracentral disc herniation of
the protrusion type is no longer evident. There is no central canal
stenosis. No significant enhancing soft tissue/epidural fibrosis/scar
is evident. A mild degree of right foraminal stenosis is noted due to
right posterior lateral bulging and facet joint degenerative changes
with encroachment upon the exiting right L4 nerve root. Progression in
this area is noted when compared to prior study. This is best
visualized on sagittal T2 weighted image 12.

L5-S1: There is a diffuse disc bulge of the annulus fibrosus measuring
less than 2 mm in AP dimension which encroaches upon the anterior
surface of the thecal sac. No significant foraminal stenosis is
evident. Minimal facet joint degenerate changes are evident. There is
essentially stable appearance at this level when compared to prior
study.

CONCLUSION:

1. Slight straightening of normal lumbar lordosis is noted consistent
with muscle spasm. Subtle dextroscoliosis of the lumbar spine is
noted.

2. There is essentially stable appearance of intervertebral disc
pathology at the L3-4 and L5-S1 levels as detailed above.

3. Since previous examination postsurgical changes are noted at the
L4-5 level as detailed above. No recurrent central disc protrusion is
evident. Right foraminal stenosis is noted at this level as detailed
above which appears to represent progression since previous
examination.

Donald Corenman, MD, DC
Moderator

August 2, 2021 at 9:07 am

Post count: 8660

#34235

Your MRI notes; L3-4: “Together with facet joint degenerate changes, ligamentum flavum hypertrophy and posterior epidural lipomatosis a minimal degree of central canal stenosis is noted. No significant foraminal stenosis is evident”.
L4-5: ‘A mild degree of right foraminal stenosis is noted due to right posterior lateral bulging and facet joint degenerative changes with encroachment upon the exiting right L4 nerve root”.
L5-S1:”No significant foraminal stenosis is evident”

Your symptoms on the left sound more like an L3 or L4 nerve root (This in in buttocks, but also down front of hip), as pain in the thigh and to the knee.irritation would be generated by the L3-4 or L4-5 level, either from foraminal or lateral recess compression. See https:
//neckandback.com/conditions/foraminal-collapse-lumbar-spine/ and
https://neckandback.com/conditions/lateral-recess-stenosis/

One of the key questions is whether the symptoms are aggravated by standing and relieved by sitting or lying down.

If so, you then can consider a selective nerve root block and a pain diary to see if this root is causing the symptoms. See:
https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/
https://neckandback.com/treatments/diagnostic-vs-therapeutic-injections/ and
https://neckandback.com/treatments/pain-diary-instructions-for-spinal-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.

BCalvert
Participant

August 2, 2021 at 9:50 am

Post count: 4

#34239

Wow. Thank you for the quick reply. I have been trying to narrow down what makes it feel better. Specifically the left side when active pain. Thinking back and thru yesterday and today, I would say laying down releives the left side pain. Sitting does somewhat but not as much as lying down. I have several things going on there so maybe they overlap?

Donald Corenman, MD, DC
Moderator

August 2, 2021 at 10:47 am

Post count: 8660

#34241

If your pain in your leg develops from activity (standing or being upright), then the noted hyperlinks I gave you would fit with those symptoms.

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.

BCalvert
Participant

August 2, 2021 at 10:52 am

Post count: 4

#34242

Thank you
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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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Problems with Stenosis after successful L4/L5 Microdiscectomy – Help please