Permanent nerve damage

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jacki
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March 13, 2013 at 4:36 am

Post count: 3

#8182

I had a TLIF at L3 L4 and fusion 4 months ago following a re-herniation having had a discectomy in February 2012. Pre operatively I had back pain but no leg symptoms. On waking from the surgery I had to spend 3 days on bed rest having had a dural tear, throughout this time I noted my foot felt numb.
Since being discharge my butt, back of my thigh, calf are numb and my foot and toes (except my big toe) are numb and painful as odd as it sounds. I had MRI and CT both indicating no problems and my surgeon suggested that the symptoms were caused by swelling around the nerve root. With no progress I had nerve studies and have subsequently seen another surgeon for review who has said that the studies indicate S1 nerve root damage and that as I have had no improvement it is unlikely now that it will get better. On reading info on the site it does look like nerves can grow back is it likely with no progress what so ever in 4 months that things may improve? I currently walk with a crutch short distances and need a wheel chair for anything other than a few minutes. I would be really glad of any advice.

Donald Corenman, MD, DC
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March 13, 2013 at 9:11 am

Post count: 8660

#8183

Your history is confusing. You had a fusion (TLIF) at L3-4 for a recurrent disc herniation. This herniation would compress the L4 nerve most likely. You note a dural tear during surgery and spent “three days on bed rest”. I do not know why you had to spend three days in bed as the normal length of time for bed rest for dural repair is 24 hours. Do you have any understanding of why three days was necessary?

The pain pattern you report after surgery sounds to be an involvement of the S1 nerve root. That is uncommon as the root most exposed at the L3-4 level is L4 or possibly L3. The dural tear might have injured the L5 or S1 root if it was a big tear with all the roots displaced and problems were noted by replacement of the roots back into the sack. If it was a large tear, the repair of the dural sack could have also been very difficult.

Is your problem pain that prevents you from prolonged walking or is it weakness of the leg? Have you had a post-operative MRI to look at the nerve roots? Did the MRI include gadolinium?

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.

jacki
Member

March 13, 2013 at 3:13 pm

Post count: 3

#8185

I have re-read the letter TLIF was l4 / l5 sorry! But the surgeon who gave me the second opinion has put the following in his letter.

“Everything points towareds S1 nerve root injury, which is slightly confusing with a 4/5 operation but on reviewing her scan it does show her to have a segmental anomaly so the actually the operation level was L5/S1 which makes sense now with the area of the injury.”

I was in bed for 3 days as I had horrendous headaches and vomiting, similar to an extreme migraine. The reason I cant walk far is a combination of increasing pain as I stand or walk and increasing weakness. The surgeon has also put in the letter that I have numbness in an S1 distribution she had weakness of the calf, absent ankle jerk and a positive slump test. I dont know exactly what the MRI included I am afraid.

I hope that is clearer
Thanks

Donald Corenman, MD, DC
Moderator

March 13, 2013 at 5:39 pm

Post count: 8660

#8186

If the operation was truly at L5-S1, this makes more sense. Three days in bed might mean that the surgeon intra-operatively had a massive tear of the dural membrane that was unrepairable and might have unintentionally injured the S1 nerve root. The headache is from the leak of the dural sack. Only when the pressure in the sack can be contained (by either repair of the sack or the CSF fluid being entrapped in a space outside of the confines of the dural sack-pseudomeningeocele) will the headache go away.

Normally for a massive tear, a diverting drain is used and bed rest for 4-5 days is standard.

This is a pressure and gravity phenomenon. If you filled a long but narrow water balloon (like the ones that are used by clowns to make balloon animals) and laid the balloon on it’s side, the pressure in the balloon would be low and equal at all points in the balloon. If you took this balloon and then held the end of it up and let it hang, you would see that the bottom section of the balloon would be wider than the top. This occurs as gravity causes the pressure of the water to be greater the further down you go to the end of the balloon.

The same principle occurs with a dural leak in the lumbar spine. When you are lying down, the pressure in the dural sack is equal from head to pelvis and you have no headache. When you sit or stand up, the pressure in the pelvis region increases dramatically and will cause the tear to leak which tractions the meninges and causes the headache.

Did you obtain a new MRI? This would give some good information regarding the status of the S1 nerve. Your tests that you noted “weakness of the calf, absent ankle jerk and a positive slump test” are all indicators of an injured S1 nerve.

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.

jacki
Member

March 13, 2013 at 10:55 pm

Post count: 3

#8194

Thank you for the reply.

The only comments made after MRI and CT were that there was swelling around the S1 nerve root, which the original surgeon thought maybe causing my symptoms. Apart from that there was no other comment made. The Nerve Conduction Studies were abnormal and indicative of S1 nerve root damage.

I guess all these weeks on with the same pattern of numbness and no improvement the Surgeon I sought for a second opinion believes that the damage to the nerve was probably caused during the dural tear. Having been told it is unlikely now to recover – i wondered if there was any way forward.

I really appreciate your response.
with thanks

Donald Corenman, MD, DC
Moderator

March 14, 2013 at 9:25 pm

Post count: 8660

#8199

You do need to give a damaged nerve time to see what kind of recovery can be made (see website under nerve injuries and recovery). If the nerve does not heal, you may be stuck with motor weakness that will not recover. Pain can be modified with medications and if chronic pain is not tolerable, a spinal cord stimulator can be considered. I would not jump into that treatment unless at least six months has passed possibly a year.

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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