Annular Tears | Lower Back Pain | Microdiscectomy vs Fusion

A valuable question and answer session off the Forum (slightly modified)

A: Back pain from an annular tear is common. I assume you have strengthened your core and have had education regarding how to properly lift, bend and load your spine. The next step is an epidural steroid injection. These are generally not a permanent cure but can yield up to a year’s worth of relief. Over time, if the disc becomes more degenerative, it is possible that the disc can stiffen and become less painful. There are individuals who develop IDR (isolated disc resorption) and need surgery but many individuals can improve over time.

I cannot tell you if you need surgery as that issue is somewhat more complex that the information we have shared here. See: When to Have Surgery to understand this issue.

Normally, as the disc degenerates further, the patient will reduce their activity to a tolerable pain level but some patients will continue to have pain that is impairing in spite of activity reduction. Degenerative disc disease is generally a genetic problem so your additional level of L4-5 is not surprising. It may be that this level is not symptomatic and the original L5-S1 level is causing all your pain.

Q: I still have a good amount of pain in my back. Not sure really how it would be relieved. When talking about surgery, are we talking about a discectomy or a fusion? I am just 24, and would not want to have a fusion as it will put more stress on other levels and i might end up having a cascade of surgeries. Would a discectomy help in my case as it is a herniated disc only although it is otherwise quite healthy and not degenerated a lot?

A: If your back pain is more one-sided (unilateral) and on the same side as the herniation, you have a better chance of back pain relief with a microdiscectomy. With unilateral pain on the same side as the herniation, the chances are about 70% for acceptable relief. If the back pain is central in nature, the chances of relief with a microdiscectomy are more like 50%

Q: I have more of a central pain. I am actually very confused here. I see a lot of patients who have leg pain, tingling, etc which means they have an annular tear with a larger herniation which I do not have. I have a herniation, which bothers no nerve. Still i see them doing great after a microdiscectomy, which in my case would have only 50℅ chances in relieving my pain although my condition is not worse as them.

A: That is correct. Surgery for a herniated disc (microdiscectomy) that causes leg pain has a success rate of over 90%. A microdiscectomy surgery for central back pain has a 50% chance of good relief (70% if unilateral pain). The reason is about half the time, the herniation causes tension on the posterior annular fibers, which is painful. Removing the herniation therefore stops the tension of these fibers and relief is gained.

The problem is the other 50% of discogenic pain is pain not due to tension on these annular fibers but due to abnormal mechanical motion of the disc and this pain can only be resolved by fusion. There is no current testing we have to determine if this disc pain is one or the other so you either choose a microdiscectomy with the knowledge you have a 50% chance of relief and then consider a fusion if no relief is gained or consider a fusion initially with a higher chance of success (90%). Or you can try to live with the pain and adjust your lifestyle, as even though this pain is impairing, it is not dangerous.

Q: This kind of goes in line with the research i have done from internet. Please correct me if i am wrong.

When a radial annular tear happens inside out but not tearing the outer layers and nucleus exudes into the layers, it gives a discogenic pain and there is no specific known reason for this pain and body does not have any way to heal it and it always remains the same. But when the tear crosses the outer layers, where there are very sensitive nerve endings, the nucleus that flows out might irritate these nerves and cause inflammation and hence pain. Hence, in a discectomy, the nucleus and the painful torn outer layers are removed and sealed using RF, which gives relief from this inflammation and reduce pain but the internal tear still remain there and discogenic pain still persists. Discectomy only does half of the work essentially.

A: RF is radiofrequency ablation is the use of an electric current to generate heat to “melt” the outer annulus. Through multiple trials, RF has been demonstrated to be ineffective for “sealing” the outer disc.

Q: If i am right here, I have few questions: how good the sealing of the outer layers is done so that there is not a re-herniation again and what’s the rate of the re-herniation after a discectomy?
How bad can a discogenic pain be? And how to deal with it for lifetime, since i am in my youth now? I believe Tylenol is a medicine which works great to reduce its pain, but would it be fine taking it often whenever there is a heavy pain?

A: The rate of re-herniation after a discectomy is about 10-15% in an active population. The disc is avascular (no blood supply) so the disc cannot heal the through and through tear. A scar does form on the outer wall but it is only about 30% as strong as the original annulus. As long as you stay below the maximum daily dosage of Tylenol, you should be OK but if you take it daily, every 6 months a liver function blood test would be helpful.

Q: How does it work in disc bulge, because essentially there is not a tear in the outer layers and nucleus does not flow out, and if there is no nucleus flowing out, it would not cause inflammation on the outer sensitive nerve endings, but still a discectomy is prescribed in a disc bulge, how does discectomy work in a disc bulge?

A: A disc bulge implies that the posterior wall of the disc is protruding out. This means the annular fibers have stretched making them incompetent. Some fibers are torn and others have elongated.

The difference between the two surgical discectomy scenarios (50% vs 70% relief) has to do with whether the pain is generated by the annulus or by nerve root compression. If the pain is one sided (on the side of the herniation), a good percentage of these patients actually have nerve root compression pain that does not radiate down into the buttocks but stays only in the off-midline side of the herniation.

The more the nerve is inflamed due to the size and location of the herniation, the more pain will radiate pain down the root’s pathway toward its terminus. Likewise, when the nerve inflammation is improving, the pain centralizes. That is, the pain recedes up the root to its origin (the side of the lower back at the level of the root). I see this all the time. If however the annulus is stretched causing local central lower back pain, the chance of improvement is only 50% with surgery.

Q: Can you tell me what is the source of the pain coming from annulus? Is it due to the annulus being stretched causes the outer layers to stretch where there is herniation, and that causes pain or is it something else? And is it related to the other 50℅ discogenic pain that we were talking earlier?

A: The annulus is highly innervated with nociceptors (pain fibers). We know this from microscopic work identifying pain nerves in the annulus and with ill-performed discograms, a test used to determine pain generation capacity of the disc.

With a normally performed discogram, a needle is placed in the center of the disc and fluid is forced into the nucleus of the disc through a syringe to pressurize the annular walls, looking for a pain response. If however, the needle is accidentally placed in the annulus (which can happen if the discographer is not accurate with needle placement) there will be reliable lower back pain reproduced every time depressing the syringe plunger pressurizes the annulus.

Most of the pain fibers originate from the outside of the disc wall and enter through the sides. There is also nerve supply that enters through the vertebral body. Interestingly, if there is a tear of this annular wall, pain fibers grow into this tear along with blood vessels and sensitize the disc even more.

Q: This is what microdiscectomy does not fix, right? The discogenic pain that arises due to the nucleus pressure or pressure received on annulus during any activity like running, jogging, biking, travelling in a car.

A: Microdiscectomy can only fix the pain which is associated with tension of the outer layers of annulus. Removing that portion of disc and cutting some fibers under tension and ablating them relieve tension.

Aberrant motion of the disc is what a microdiscectomy will not fix. The disc is designed to restrict motion, like a bushing. With annular tears, the disc motion initially increases and the disc moves in ways that increase the stress on the more intact but injured annular fibers. This leads to further damage. In some discs, this motion continues to destroy the disc wall and endplates, eventually leading to isolated disc resorption (Isolated Disc Resorption Lumbar Spine (IDR)).

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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.

Discussion of Annular Tears and Lower Back Pain, Microdiscectomy or Fusion?

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About the Author: Donald Corenman, MD, DC

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