about foraminotomy

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exercise453
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May 10, 2012 at 9:11 am

Post count: 53

#6176

Hi Doc….Appreciate the site and forum

Why is a posterior foraminotomy done vs an endoscopic posterior foraminotomy? Is it some difference in the position of the herniation/osteophyte? The first Peyton Manning posterior scar looks like it was not an endoscopic procedure.

Can these be done at two consecutive levels-symptoms on one/same side ?
c3-c4…c4-c5

Can they be done to a “posterior-osteophyte complex without evidence of cord compression and mild narrowing of the spinal canal, bilateral lateral extension resulting in moderate neuroforaminal stenoses”…..but the symptoms are all on one side.

Even in the case of a posterior central disc with lateral extension can fusion be avoided if symptoms are only on one side?

Thanks so much

Donald Corenman, MD, DC
Moderator

May 10, 2012 at 10:42 pm

Post count: 8660

#6177

You have two questions regarding posterior foraminotomy. One is surgical technique and one has to do with indications.

Foraminotomy is performed for foraminal stenosis, the compression of a nerve root in the foramen from a herniated disc or bone spur. If the source of compression is a herniated disc, this disc fragment must be in the foramen and not under the cord in the front of the canal. If the fragment to too far forward, manipulation of the spinal cord to remove the fragment is necessary which in my opinion, puts the spinal cord at risk for injury.

If the compression is from a bone spur, there are two potential origins of the compressive spur; the facet or the uncovertebral joint. If the spur originates from the facet, then the foraminotomy will generally be successful as this procedure removes about 1/2 of the medial facet and obliterates this spur. If the spur however originates from the uncovertebral joint (which is more common), the bone spur cannot be removed completely and there are more failures from this procedure in this case. The reason is that the uncovertebral joint is in the anterior half of the spine and this procedure is posteriorly located which limits access to the spur.

The procedure can be performed open or through a tube. I use the tube but any surgeon who performs this procedure without a tube will most likely have the same results. The endoscope is a small camera attached to the end of a wand. I use a microscope as there is more working room to see the global picture but there is nothing wrong with using an endoscope. Either technique should elicit the same results.

The key to this procedure is to make sure you have the correct diagnosis. I just saw a patient who had this procedure performed at another institution and had increasing pain after the procedure. The reason was that his pain originated from an arthritic facet and had nothing to do with his foraminal stenosis. Make sure the correct pain generator is identified (see section on diagnostic nerve and facet blocks).

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.

exercise453
Member

May 11, 2012 at 1:26 am

Post count: 53

#6179

There is something else doc, if I may. From a “giving way” (unilateral) during an incline bench press I may have affected every disc to some degree, c4-t1. Other traumas make it a diagnostic nightmare.

There is a prominent white line running laterally across the spinal cord at c6-7. It is identical in an mri a year and a half ago and again in a recent one. You could not miss it if you were blind.

Different radiologists do not even mention it and all the cord findings are normal.

What could it be and is it worrisome?

Thans again

Donald Corenman, MD, DC
Moderator

May 11, 2012 at 10:53 pm

Post count: 8660

#6182

The injury when weight lifting could have some consequences but these should be able to be diagnosed appropriately with the appropriate physical examination and testing.

A white line running across the cord could be a mach line. This is a shadow that can occur from tissue density (the shoulder), a metal artifact (a tooth filling) or something else. The fact that it is there exactly in the same place on every scan is somewhat weird but if not noted by the radiologists, is probably just an artifact.

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.

exercise453
Member

May 20, 2012 at 4:21 am

Post count: 53

#6229

Hi Doctor,

Assuming symptomatic levels can a foraminotomy be done above a fusion level given the correct indications (c3-4 over c4-5 fusion to avoid a double)?

Same question c4-5 fusion over a c7-t1 foraminatomy?

You say there is a return to most activities after a single and sometimes double fusion. Can a golfer return to golf and jerk his head to the left (involved side) hundreds of times a day, week and so on?

Thanks

Donald Corenman, MD, DC
Moderator

May 20, 2012 at 11:09 pm

Post count: 8660

#6232

Foraminotomies can be performed at any level in the cervical spine as long as the indications are correct ands there are no contra-indications (degenerative spondylolisthesis, central disc herniation, bone spur originating from anterior uncovertebral joint). The procedure is performed for nerve compression (arm pain) and not for neck pain.

After a single level ACDF, my patients can go back to the NFL. Even with a three level ACDF, patients can go back to golf. Two levels are the maximum if they are professional golfers. Artificial disc replacement allows more levels to be surgically involved.

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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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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