Re-current Herniation Opinion

Tagged: 3rd herniation in same place in lumbar spine

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nyquist
Participant

March 23, 2022 at 12:40 pm

Post count: 4

#34970

Hi Dr. Corenman,

I would love your opinion on my thrice-herniated L5-S1, specifically if you would ever recommend a 3rd discectomy or insist on something else (fusion or artificial disc).

I had a discectomy/laminectomy in Feb 2021 and I am pretty sure it immediately reherniated as the pain was slightly improved but still bad right away. My surgeon refused a second MRI until 6 months post-op, which did show a significant new herniation.

I left for a new practice who performed a minimally invasive discectomy in February this year, which was light years easier to recover from. I had 3 weeks of improving pain to the point where it was just about gone before it suddenly came back (butt and leg pain) at the 3 week mark.

I had a new MRI last week that showed a new, albeit smaller for now, herniation at L5-S1. The report also noted a moderate to severe left foraminal narrowing. The surgeon wants to do another minimally invasive discectomy to cleanup the new herniation. I wanted to see if you ever recommend a 3rd discectomy or if you would move to a more invasive procedure at this point.

Thank you very much for your insights. I put the important parts of the report below, the rest of the spine is “there is no evidence of focal disc protrusion, spinal canal stenosis, or foraminal stenosis.”

Full Impressions:
Interval postsurgical changes from right hemilaminotomy at L5-S1 with
grossly unchanged right subarticular disc protrusion and grossly unchanged
mass effect on traversing right S1 nerve roots. Unchanged foraminal
narrowing at L5-S1. Findings could represent recurrent disc protrusion or
granulation tissue. Contrast enhanced examination could be obtained for
further evaluation if clinically indicated.

At L5-S1, there are postsurgical changes. Again noted is a right
subarticular disc protrusion with mass effect on traversing right S1 nerve
roots. There is mild right and moderate to severe left foraminal
narrowing, grossly unchanged.

The conus medullaris is normal in position and appearance. There is no
evidence of epidural mass, fluid collection, or hematoma. The
paravertebral soft tissues are unremarkable.

Donald Corenman, MD, DC
Moderator

March 23, 2022 at 2:39 pm

Post count: 8660

#34971

Generally, it is recommended to do a fusion if the level has already had 3 herniations (HNP). The reason is scar generation, 4th recurrent HNP and the “battered root” syndrome.

These roots don’t like to be manipulated too many times as manipulation can cause root damage even without recurrent HNPs so the fewer surgeries to free the root, the better. We have figured that 3 decompressions should be the maximum number to prevent battered root.

A disc that has already spit 3 herniations out can easily herniate again. For the first three HNPs, it is noted that recurrence rate is about 10-20%. However, after the first three, the reherniation rate goes up possibly to 50%

Finally, every time the root is decompressed, there is scar that forms. This scar only multiplies with each subsequent surgery. Again, it seems like three is the magic number here too.

Then finally add severe left foraminal stenosis due to the loss of disc height and degeneration bone spurs that occur. This will not get better with a redo surgery but could get worse and become symptomatic. I would advise a decompression and fusion of this level.

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.

nyquist
Participant

March 24, 2022 at 8:28 pm

Post count: 4

#34976

Thank you so very much for the reply. I really appreciate it!
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Donald Corenman, MD, DC

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81 reviews

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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