not fused 16 months post tlif

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MASpinept
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December 2, 2021 at 7:21 am

Post count: 17

#34661

Hi dr. Corenman,

I have posted a few questions throughout my surgical journey, i am in the process of scheduling a long distance consult with you, i’m just waiting to hear back from your office. I look forward to getting your opinion on everything. IN the meantime i was hoping you could offer an opinion.

I am 16 months out from L5 S1 tLIF for recurrent herniation causing leg weakness, also i had an l5 pars fx and spondy which developed from the 2 pervious laminectomies that were also done) urgently) for a disc herniation that caused footdrop. My symptoms improved at about 8 months post the TLIF and i started ramping up my activity at that point. Unfortunately shortly after doing so many of my pain and nerve sx became more noticeable and have continued to get worse and worse. I started pushing my surgeon’s office for imaging and they discovered i am not fused.

I have had 2 Cts in the past 5-6 months and i am not fused at all in the posteriolateral areas and apparently i am 80% in the anterior, but not anterior to the cage. The radiologist calls this fused area “minimal” but my surgeon said it is enough. Both radiology and surgeon agree posterior is not fused.

I was under the impression that i needed a revision but now i am being told that all my symptoms are from my 3 surgeries and are related to scarring and nerve damage of my cauda equina (which i didn’t realize was ever damaged). I am not ready to give up. I am hoping you can help.

I find it hard to believe that the spine pain at the end of the day and into the night is all related to nerve damage. It feels like bone pain and it radiates to my tailbone and spreads into my pelvis and it’s intensity is dependent on how active i have been during that day. Below is the CT report. Thank you!

Indication: Assess fusion status post lumbar spinal fusion.

Technique: Helical CT of the lumbar spine was performed according to routine
protocol. The helical data set was reformatted in the sagittal and coronal
planes. Additionally a 3-D model of the data set was performed at an
independent workstation.Dose reduction techniques were utilized including mA
and/or kV adjustment.

COMPARISON: CT lumbar spine from 7/9/2021.

Findings:

Hardware: Fusion construct at L5-S1 with bilateral transpedicular screws and
connecting rods. Intervertebral spacer noted at L5-S1. No perihardware
lucency to suggest loosening. Screws appear to be in the expected location.
Hardware appears intact.

Osseous Fusion: At the left L5-S1 facet joints, there is marginal bony
bridging, similar in appearance to prior CT. No joint gas identified suggest
excess motion. No right posterolateral osseous union identified.

At the L5-S1 disc space on the right, there is minimal bony spicule
formation, similar in appearance to prior study, which may span the height
of the disc space. No intervertebral disc gas to suggest excessive motion.

T12-L1: No significant central canal stenosis. No neuroforaminal stenosis.

L1-L2: No significant central canal stenosis. No neuroforaminal stenosis.

L2-L3: Mild bilateral facet arthropathy. No significant central canal
stenosis. No neuroforaminal stenosis.

L3-L4: Mild right facet arthropathy. No significant central canal stenosis.
No neuroforaminal stenosis.

L4-L5: Shallow concentric disc bulge with mild left facet arthropathy. No
significant central canal stenosis. No neuroforaminal stenosis.

L5-S1: Status post right partial hemilaminectomy and medial facetectomy. No
significant central canal stenosis. No neuroforaminal stenosis.

The imaged upper sacrum and upper iliac bones appear unremarkable.

The imaged retroperitoneum appears unremarkable.

Donald Corenman, MD, DC
Moderator

December 2, 2021 at 3:31 pm

Post count: 8660

#34662

It is very common to have some initial improvement from a TLIF decompression and fusion but have symptoms “show up” 6-8 months after surgery due to pseudoarthrosis. (“My symptoms improved at about 8 months post the TLIF and i started ramping up my activity at that point. Unfortunately shortly after doing so many of my pain and nerve sx became more noticeable and have continued to get worse and worse. I started pushing my surgeon’s office for imaging and they discovered i am not fused)”.

Generally, if you have local back pain (central pain-not unilateral) some time after fusion is unsuccessful, this pain is generated by the spine itself (the non-united bone fragments press together). Unilateral pain at the L5- S1 level can be either pseudoarthrosis or nerve related. Pain in the SI joint or buttocks on one side more likely is nerve irritation.

How would you characterize your pain in percentage lower back to leg and how does it change with activity?

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.

MASpinept
Participant

December 2, 2021 at 5:54 pm

Post count: 17

#34663

Well it’s variable; I would say the leg pain and back pain can exist together or apart and aggravation and pattern is not consistent between the two. The right leg I have frequent nerve pain from buttocks to toes, mostly L5 and S1 (and this is chronic damage from the multiple injuries and surgery, I never expected that this pain would go away even after the fusion). When I am active I get symptoms more on the front of my leg and into my big toe, sometimes this happens on my right toe as well but does not follow such a specific pattern on the left leg.

For the back pain, it’s always best in the mornings and by about 2-3 pm it starts getting worse, evening and night time are very uncomfortable. I try to walk 1-2 miles daily even now, despite having had to peel back most of my activities. At first I feel fine during exercise and then I start getting pain that feels directly in my spine, sometimes it will spread out like a cross but not always. Lately I get very specific sharp pain that feels very close to the top left screw, this is definitely bone pain and it doesn’t radiate too far from that spot. Immediately after being active my back feels locked up. Once I stop moving and then as the day or evening go on my back just aches and aches, it feels like the area around the screws, sometimes it feels hot and inflamed. I can feel the screw heads very easily when feeling my back, it hurts to lay on hard surfaces so that is how I am able to tell where they are, if that makes sense.

The night when the pain is very bad it feels like a combo of pain in my entire lower half of my body. It feels like throbbing pain in my spine that goes down to my tailbone, then it will involve my hips and radiate down to my legs as well, but the leg pain associated with this isn’t the specific nerve pain, but sometimes that specific nerve pain is there at this time, as well. Additionally I get a lot of muscle twitching and restless leg feelings (also something I am not expecting to ever go away).

The worst activity is running, which I have stopped doing since the summer. Although now horse back riding, specifically posting at the trot, has become very painful and almost not worth it, I have basically stopped that as well. Peloton is the only exercise that doesn’t cause a lot of discomfort after.

Sorry this is so long winded, just trying to specific with the pattern of pain!

Donald Corenman, MD, DC
Moderator

December 3, 2021 at 11:56 am

Post count: 8660

#34664

Your pain pattern sounds like bone pain (pseudoarthrosis) but if a solid fusion is present, it could be hardware pain. The CT scan will be very important to review as it sounds like you have lack of fusion. You might need an ALIF to repair your 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.

MASpinept
Participant

December 3, 2021 at 12:39 pm

Post count: 17

#34665

Yeah, I look forward to speaking with you more about it. I believe I have a tentative appointment for a long-distance consult with you next week, just waiting to hear back from the office to confirm. I’m interested to see your thoughts and interpretation of everything.
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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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