2 year injury to low back. What should I do?

Tagged: Lower Back Annular Tear

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jmdockery2
Participant

October 19, 2019 at 1:10 pm

Post count: 4

#31322

Dr. Corenman,

I am a 32 yo male and had an original injury to my left lower back 2 years ago while lifting in which I felt a pop. Later that evening I began to experience mild tingling in the medial aspect of my left foot. For the next couple months, the tingling in my foot became more constant and I experienced a progressive soreness and stiffness in my lower back.

I tried an ESI that did not have an impact on my symptoms. I also did a bout of PT in which I didn’t respond to treatment. About 6 months after the original injury I began experiencing similar symptoms in my right leg and foot. There was no trauma or incident that I know of that lead to these right leg symptoms.

As time went on, the nerve pain in both legs progressed. The symptoms of nerve pain in the feet/legs and soreness/stiffness in my lower back are exacerbated with standing and walking more so than sitting. The nerve pain is constant but is reduced with Lyrica (200 mg 3x per day) and lying down. Stinging/burning/aching is experienced in top of feet, medial arch, and plantar aspect of feet more so than in back of thighs and calves.

I have had multiple supine MRIs that show no more than mild disc bulging at L4/L5 and L5/S1. They have also identified a small Tarlov cyst located in the left S1/S2 foramen. Since my symptoms were worsened in standing I got a standing/functional MRI that showed nothing more than the supine MRI per report. I had a discography performed at L3, L4, and L5 disc that revealed a Grade III (full thickness annular tear) at the L5/S1 disc. I attempted more epidurals and a PRP injection with no success.

The neurosurgeons I have consulted with do not feel like there is anything surgical to consider. However, this is significantly impacting my quality of life and my activity level has severely decreased because of pain and discomfort.

I have pushed through this for a long time but don’t know how much more I can stand. Any advice on what my next step should be, if any? I highly appreciate this.

jmdockery2
Participant

October 19, 2019 at 1:13 pm

Post count: 4

#31324

Also,

I have had NCV and EMG testing done. No abnormalities on NCV. Moderate to minimal chronic denervation noted at L4, L5, and S1 musculature. This was only performed in my left side.

Donald Corenman, MD, DC
Moderator

October 20, 2019 at 11:05 am

Post count: 8660

#31328

It would be important to know the percentage of lower back pain vs. leg pain. That is, do you have 70% lower back pain and 30% leg symptoms that increases to 50% back and 50% leg when standing?

Nerve symptoms that increase with standing and walking can be generated by lateral recess stenosis and/or foraminal stenosis. DO you have flexion/extension x-rays that can uncover instability?

See https://neckandback.com/conditions/lateral-recess-stenosis/ and https://neckandback.com/conditions/lumbar-foraminal-stenosis-collapse/ and
https://neckandback.com/conditions/lumbar-spine-instability/

Negative NCVs do not rule out a peripheral neuropathy if the neuropathy is “small fiber disease”. that is, if the neuropathy occurs only in small diameter nerve roots, the NCV will not show any disorder even in the presence of significant symptoms.

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.

jmdockery2
Participant

October 20, 2019 at 12:14 pm

Post count: 4

#31332

I would say 70% leg pain and 30% back pain in standing and 80% leg pain, 20% back pain when lying down. The nerve pain is always worse as the day progresses and the more I’m on my feet.

I’ve had a standing/functional MRI with flexion and extension views but the findings didn’t reveal any instability. Now these images were performed in sitting while flexing and extending and not in standing.

I look forward to your response.

Thank you!

Donald Corenman, MD, DC
Moderator

October 20, 2019 at 12:43 pm

Post count: 8660

#31335

“Functional MRIs are not very helpful as the image acquisition time is so prolonged, you can’t stress the spine with motion well and results are commonly inconclusive. Standing flexion/extension X-rays are the gold standard for instability (if performed correctly). Leg pain greater than back pain that radiates to the feet that decreases (slightly) with standing could be root compression with spur or disc herniation but your studies don’t support that. You certainly can have peripheral neuropathy as a cause. I assume that you have no long tract signs (physical examination findings). Do covers touching your feet bother you at night or do the symptoms increase at night

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.

jmdockery2
Participant

October 20, 2019 at 12:57 pm

Post count: 4

#31337

My nerve symptoms just increase at night. The covers don’t bother my legs or feet. Negative Upper motor neuron signs. Mild hyperflexia with patellar tendon reflexes. I can get a standing flexion/extension X-rays done to assess if there is any underlying instability.

What are your thoughts on the full thickness annular tear? Is it possible the nucleus is leaking chemical irritants on the nerves?

Thoughts on the Tarlov cyst?

Again, thank you for your thoughts.
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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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