when is a foraminotomy considered?

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orthodog
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October 30, 2013 at 10:23 am

Post count: 3

#9730

Hello Dr. Corenman. We met about 6 months ago at your office in Vail. I hope you had a great summer and put many miles on your colnago:) To review I’m 16 months post laminectomy/discectomy right L5-S1. The first 4-6 months post surgery were awesome. I felt like a brand new man. But after returning to vigorous cross training, things got bad again. My GP ordered a new MRI, films, and EMG that revealed I have lumbar scoliosis due to a significant leg length discrepancy of right leg. I have a paracentral broad base disc bulge with probable impingement and neuroforminal stenosis at L5-S1 on left. I have residual chronic radiculopathy of right calf and foot from my initial herniation that is getting worse. I have severe cramping in my calves and feet. My legs tingle all night. My legs also feel heavy and weak. I have mild chronic pain along the belt line that radiates to the trochanter notch on both sides. When I last saw you I had begun to notice a little parasthesia in my left foot and some mild pain in my left buttocks.
You orederd ESI on the left side. It did not help and the tingling in my left foot has gotten much worse (numb toes on both feet) as well as the left side sciatic pain. It is not severe but is always there. The overall lower back discomfort is worse at the end of the day and the tingling is also worse. Sitting doesnt bother me at all and the yoga child’s pose feels good. Cycling does not cause pain thank God. But any type of core strengthening or cross training really makes the pain worse. I’ve completely given up running. My activity level has been cut in half and I’ve gained 20 lbs due to pain and depression. I was desperate when I saw you last. I’m more desperate now, however, I remain optimistic that you or somebody out there can fix me. And by fix me, I mean eliminate or significantly reduce the parasthesia in both calves and feet and reduce the pain to just the mild arthritic type.
You also recommended some diagnostic injections (hip, facet, SI) to aid in diagnosis, but to me this is mostly about the parasthesia in my legs and feet and the chronic pain from standing all day. It seems like the problem is the neuroforaminal stenosis. After researching, it seems like the foraminotomy is a realtively simple procedure with a high success rate. Is it time to consider this? Can/should it be combined with a laminectomy on left side? Would a revision on the right side to remove scar tissue help with chronic radiculopathy? Should I make another appointment to see you? Should I see my local surgeon (Who you said did a good job)? If you can help me doc, I’ll get you the new Campy electronic shifting gruppo:) Sorry if this hard to follow but its been a long day. Thanks

orthodog
Member

October 30, 2013 at 12:34 pm

Post count: 3

#9732

I should have posted this under the back pain forum. Sorry. Moderator please feel free to move it.

Donald Corenman, MD, DC
Moderator

November 16, 2013 at 11:43 pm

Post count: 8660

#9808

First, lets go to the injection results. You might not have had great long term results but the first three hours after the injection is the most important period of time for diagnosis. Did you aggravate the pain prior to the injection and did you keep a pain diary for the first three hours to indicate your post-injection pain level? This can indicate if the injected area is the pain generator.

Increased pain with standing and walking (running) that is relieved by flexion (bending forward-sitting, cycling or child’s pose in yoga) is generally caused by stenosis (foraminal, lateral recess or central-see website).

Foraminotomy (surgical opening of the foramen-essentially a “roto-rooter” job) can be a very effective procedure. There are however problems with this procedure in some patients. If there is severe and complete degenerative disc collapse (DDD) and/or angular collapse (severe collapse only on one side of the disc), the foraminotomy has a higher chance of failure.

This is because the disc height contributes at least 1/2 of the height of the foramen which increases the volume of this exit zone. Disc collapse, as is so common with severe DDD includes in the pathology bone spur formation on the edges of the disc which compounds the narrowing. A foraminotomy cannot remove this far lateral bone spur narrowing unless you remove the entire facet (which defeats the purpose of the foraminotomy in the first place).

For angular collapse, the bone spurs in the foramen grew there in the first place to support the spine and prevent further collapse. By removing these spurs in a foraminotomy, there is a higher chance of further angular collapse and re-compression of the nerve. This is why some patient can undergo a foraminotomy and have 2-3 months of symptom relief only to redevelop symptoms sometime after surgery.

By the way, I am a curmudgeon with my bikes. I would hate to be out on the road and have the battery run out on my derailer on my new gruppo. I love Campy but prefer the simple and reliable cable system.

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.

orthodog
Member

December 3, 2013 at 12:23 am

Post count: 3

#9889

Hi Dr. Corenman. Thanks for your reply. Sorry it has taken me so long to reply to you. I was actually very sore after the injection for about 3 days. The tingling in my foot and calf improved for a few weeks but has returned even worse. The sciatic pain has not changed…mild to moderate constantly with exacerbations with any type of core engagement.

I saw my local surgeon last week. He thinks a left side laminectomy/foraminotomy are imminent but wants a new MRI with contrast and flexion/extension xrays to rule out chance of instability. This is probably my biggest fear….I know that post decompression instability is the indicator for a lumbar fusion, which terrifies me. When i get my new films I’d like to send them to you for another consult. I also have questions on a minimally invasive procedure vs an open procedure? Your thoughts?

Thanks and sorry about the electronic gruppo comment. I should have known you were a purist :)

Donald Corenman, MD, DC
Moderator

December 4, 2013 at 8:01 pm

Post count: 8660

#9894

Your response to the injection was not one that easily confirms the diagnosis of foraminal stenosis. If you were “very sore” after the injection and could not recognize improvement for the first three hours (when the lidocaine is effective), then the diagnostic portion of the injection is lost.

This does not mean that the correct diagnosis is not that of foraminal stenosis but that the injection technique causes new and additional pain that masked the results of the numbing medication. Feeling better 3 days later does not constitute a successful diagnosis as the steroid injected is not specific and can relieve inflammation a level or two away from the injection site.

Foraminotomy can be successful if there is no angular collapse (seen on the standing AP X-ray) and no instability (seen on the flexion/extension X-rays). There should be no difference between the “minimally invasive” procedure and the “open” procedure but the failures I have seen (if the patient was a good candidate for a foraminotomy in the first place) are a higher percentage in the “minimally invasive” group.

I do review films but it does take quite a while for me to see them and get back to you. You can call the office for more information.

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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