Chronic Radiculopathy

Chronic Radiculopathy Overview

Nerves are persnickety creatures. They can generally tolerate some compression but don’t really like to be pushed around. Unfortunately, there are many conditions of the spine that cause nerve compression in the spine. A herniated disc of the spine, spinal central stenosis, lateral recess stenosis, and foraminal stenosis, as well as foraminal collapse, are but a few of the compressive conditions that can cause nerve pain leading to lower back pain and leg pain.

Even though there are many occasions where severe nerve compression in the spine causes no long term after effects, it can occasionally permanently damage the interior workings of the nerve. A decompression surgery of the nerve (microdiscectomy of the lumbar spine or lateral recess decompression) will generally take the pressure off the nerve and in 90-95% of the cases the nerve will recover.

What about the other 5% of cases where persistent lower back pain is common? If there is no further compression of the nerve (a new MRI after surgery in the face of continuing pain demonstrates no further nerve compression in the spine) and there is not a pinched nerve in the spine or no instability of the spine within the segment that can cause intermittent mechanical compression, then these symptoms represent chronic non-healing injury to the nerve root or “chronic radiculopathy”.

Stretch can also lead to a nerve injury of the spine leading to nerve pain, lower back pain, and leg pain. This is much more common in the arm where “stingers” are stretch injuries of the brachial plexus (the shoulder nerves) but the sciatic and femoral nerves in the legs can also be stretched and injured. A nerve injury in the spine can occur from sports, impacts and even rarely, slip and fall accidents.

(Click to Enlarge Image)

(Click to Enlarge Image) Schwann cell nerve injury and conduction block.

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(Please keep reading below for more information on this condition.)

Post-Surgical Non-Pain Related Nerve Symptoms

If surgery is warranted to decompress the nerve, some patients may observe unusual symptoms in the leg after surgery. With the intense pain now gone, patients can experience some symptoms that were present prior to surgery but were not noticed because the preexisting intense pain from nerve compression overshadowed these symptoms. Some will complain of “bugs crawling” and others will be sure that someone spilled cold water on their leg but when they glance at their leg- it is dry. This alteration of symptoms (referred to as spinal cord dysfunction) will most likely eventually disappear but it may take as much as six months.

Mechanics of Nerve Injury and Spinal Cord Complications

The nerve root is a compilation of sensory and motor nerve cells. Any nerve cell is simply a long tube that connects the brain to the end point structure (the foot, thigh, buttocks, hand, shoulder, etc.). In fact, the nerve cell is the longest cell in the body with some reaching up to three feet in length. These structural tubes are made of membranes with “pumps” that continuously push potassium and sodium into and out of the cell to maintain a charge of electricity across the membrane. This electrical charge is what allows the signal to travel up or down the nerve.

If the membrane of the cell is damaged and becomes “leaky” or the blood vessel that services the nerve membrane pump is injured, the cell membrane will become dysfunctional. That is, the nerve may deliver a signal to the brain even though the sensor on the end of the nerve doesn’t trigger it (an ectopic focus) or block a signal that should have been transmitted. If the nerve carries ectopic pain signals, the brain perceives pain. If the ectopic signal is from a proprioceptive nerve (position sense), pins and needles sensation will be perceived by the brain. If the motor nerve is injured, the muscle attached to that nerve will be weak and if the nerve is in the leg, a limp may be noticed.

This means that in the face of a pain nerve injury, nerve impulses will travel up to the brain on a fairly constant basis. Pain can be described as constant “burning”, “raw” and “gnawing”. Hypersensitivity of the skin (hyperalgesia or allodynia) can occur. A simple brushing of bed sheets on exposed skin can cause intense pain. This is referred to as peripheral neuropathy.

A good example of this phenomenon is “phantom pain syndrome”. Some unfortunate individuals with an amputation of the leg will still complain of “foot pain”. The nerve at the amputation site still conducts an impulse and the brain is wired to perceive “foot pain” even though there is no foot!

This type of chronic neuropathic pain can be managed and controlled with medications and nerve stimulation. Years ago, Melzak and Wall won a Nobel Prize when they introduced the “gate theory of pain”. We all have unknowingly used this discovery when we were kids. When our arm or leg was injured, we would vigorously rub the skin of the injured area and the pain would disappear. What would be occurring is that our stimulation of the skin would “flood” the sensory system and the “gate” to the pain pathway would be “closed”.

The TENS unit (transcutaneous electrical neural stimulation) works off this principle. Pads placed on the skin conduct an electrical signal from a small generator, which blocks the pain signal. This stimulator substitutes the electrical stimulation of the skin for the intense skin rubbing and actually substitutes “white noise” for pain perception.

An implanted spinal cord or implanted peripheral stimulator uses this same technique to reduce pain. Stimulation of the skin or spinal cord floods the sensory system and is designed to reduce pain. Implanted stimulators tend to have better signal production and can reduce pain much more than TENS units but of course, require an operation for implantation.

If you are experiencing ongoing, persistent symptoms associated with a pinched nerve in the leg, nerve compression in the spine, or if you are chronically suffering from leg pain, lower back pain and nerve pain, please contact Dr. Donald Corenman, Vail, Aspen, Denver and Grand Junction, Colorado back doctor and spine specialist, for additional information on chronic radiculopathy.

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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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