4-level ACDF

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whatthe2
Member

July 5, 2012 at 12:25 am

Post count: 8

#6482

Dr. Corenman,

Thank you very much for setting up this forum.

I am a 41 year-old male and have been to several surgeons and treatment recommendations have been from one end of the spectrum to the other so I’m very confused on what needs to be done to fix my problems.

Symptoms:
My symptoms started just over 5 months ago with pain in my right shoulder blade. As the weeks progressed, I developed excruciating pain down my right arm (both on the inside and outside of the arm), numbness and slight loss of function in my right arm. Currenly, the pain in my right arm is much better, but I do have occasional pain in the upper right arm depending on the day. I also notice slight weakness compared to my non-dominant left hand. I have slight pain in my neck, but quite a bit of numbness in the neck (mostly on the right side). I also still have pain in my right shoulder and shoulder blade which varies in severity.

MRI Results:
Findings:
No bone marrow contusion or fracture is seen. Moderate muliple disc desication is seen with some protrusions. There is straightening of the typical lordosis of the cervical spine. Facet joints align normally. Included imaging of the posterior fossa, cervical spinal cord, and proximal thoracic spinal cord all appear unremarkable.

C2-C3: Minimal diffuse disc bulge with a mild focal central protrusion. Mild facet arthropathy. No significant center canal or neural foraminal narrowing.

C4-C5: Moderate right paracentral focal protrusion with mild diffuse disc bulge. Mild left greater than right facet arthropathy is seen. Findings result in moderate left and mild right neural foraminal narrowing. There is mild/moderate central canal narrowing with some deformity of the anterior cervical spinal cord to the focal protrusion.

C5-C6: Asymmetric right mild diffuse disc bulge with mild bilateral facet arthropathy. No significant center canal or neural foraminal narrowing.

C6-C7: Mild to moderate diffuse disc bulge with moderate left lateral focal protrusion. Mild bilateral facet arthropathy. Severe left and moderate to severe right neural foraminal narrowing is seen. There is mild central canal narrowing with effacement of the anterior CSF space.

C7-T1: Unremarkable

Treatment:
I’ve tried physical therapy with no relief. I’ve also had three steroid injections. Two in the C6-C7 nerve and one facet block in the C6-C7.

Measurements of spinal canal:
I’ve been told I have Congenital Cervical Stenosis.
C2/3: 11mm
C3/4: 9mm
C4/5: 6mm
C5/6: 9mm
C6/7: 7mm
C7T1: 9mm

One surgeon (that did the measurements above) recommends a C4-T1 ACDF. Others have definitely been concerned about the C4/5 and C6/7 discs as they say the dangers in the cord compression and my pain/numbness symptoms won’t get better and there is risk of paralysis and they believe there is already damage from the cord compression. Some have recommended only an ACDF of C4/5 and C6/7 while others have said to wait and see if the symptoms improve.

I’m wondering if you would be able to give your opinion based on the information I’ve provided. I can also send you the MRI if that would be helpful. The one thing that doesn’t really make sense is the MRI report lists the C7/T1 as unremarkable, however I can definitely see some protrusion and compression.

Thank you very much.

Rick

Donald Corenman, MD, DC
Moderator

July 5, 2012 at 5:00 am

Post count: 8660

#6484

Pain in the right shoulder and arm associated with weakness is typically a nerve root compression syndrome. That is normally from foraminal stenosis. The physical examination is normally very revealing to identify the involved root or roots. Weakness of the deltoid muscle is C5; weakness of the biceps is typically C6 and weakness of the triceps is involvement of the C7 root.

Sensory involvement is along specific dermatomes (discreet patches of skin) tested by a pinwheel. FInally, neck extension (bending backwards) can cause increased pain from further narrowing of the foramen.

Your MRI notes at C4-5 (C5 nerve) “moderate left and mild right neural foraminal narrowing”. If the radiologist has read this accurately, this level has only mild nerve compression on the right so that level is less likely to cause symptoms.

At C5-6 (C6 nerve), the radiologist notes “no significant center canal or neural foraminal narrowing”. If he is correct, that level can be ruled out.

At C6-7 (C7 nerve root), “severe left and moderate to severe right neural foraminal narrowing is seen. There is mild central canal narrowing with effacement of the anterior CSF space”. That sounds like the level of major involvement both with nerve compression and central canal narrowing.

The surgeon you consulted with noted relatively severe narrowing of the spinal canal but that was not noted by the radiologist. The radiologist did note mild to moderate narrowing of the canal at C4-5 but mild at C6-7.

Break the problem down into what is currently causing symptoms and what could cause a potential injury in the future. More likely than not, C6-7 is causing your current symptoms of right arm and shoulder pain. You have had two epidurals at C6-7. Assuming they were specific (the injectionist did not flood the canal and drove the medication up to C4-5), how did you do for the first three hours after the injection (see pain diary on the website)? If you had good but temporary relief, the C6-7 level is causing your shoulder and arm pain. This will have to be addressed with an ACDF or ADR (see website).

The next question is the C4-5 level. If the narrowing is severe (and there appears to be a disagreement between surgeon and radiologist), possibly the level might need to be addressed surgically. If you do not participate in situations that put your neck at risk, (mountain biking, horseback riding, motorcycle riding, etc..) you might be able to live with that level with some mild inherent risk.

If you do put your neck at risk or do not want to live with the risk, two surgeries can be contemplated at C4-5, an ACDF (fusion) or a laminectomy. Based upon the limited information here, you do not need a 4 level ACDF.

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.

whatthe2
Member

July 5, 2012 at 8:50 am

Post count: 8

#6486

Dr. Corenman,

Thank you very much for your reply (especially on a Holiday).

I’m in Denver and will actually be in Vail in about a week and half so I will be calling your office tomorrow to schedule a visit. If that is too soon, no matter, I will make the trip to Vail when you are available.

You mentioned that neck extension (bending backwards) can cause increased pain from further narrowing of the foramen. Bending my head backwards (and to the right) causes me the most amount of pain and discomfort.

I think you are spot-on with your assessment that C6-7 is causing the problems at this point. The first Epidural was directly into C6-7 and I didn’t have much relief to speak of. For the second Epidural, they went in under the T1 and then up the right side to the C7 and I had immediate relief and significant relief for a couple weeks. The third (Facet block in the C6-7) didn’t provide any relief. Nothing has been done to the C4-5.

Regarding the C4-5 narrowing, I’m with you that there is a discrepancy between the Radiologist and the Surgeon I saw most recently. That is what is causing me the most concern at this point. I do not participate in activities to put myself at risk, but I’m not certain if I am currently doing damage to the spinal cord at this point or not. I understand that if I get in a car accident or fall, etc. I could have problems, but am I doing damage as we speak? The last surgeon left me with the feeling that I am doing damage right now and it will continue to degrade until it’s fixed. (This may require further evaluation on your part, so I understand if you can’t answer at this point).

Regarding ADR, none of the surgeons mentioned this as an option to me, but I did find out about this as I did some research. I mentioned this to the last surgeon I saw, but since he was recommending a 4-level, an ADR was out of the question. If this is still a possibility, I’m all for looking into it.

I definitely would like to explore tackling the two issues that seem to be the most critical at this point (the C4-5 and the C6-7). I can live with the pain and discomfort (for now), and look forward to meeting you in person for a more thorough examination, but at this point do you think there is reason to be concerned that I’m doing permanent damage to my spinal cord in C4-5 because of the compression? I’d rather not rush into making a decision if I still have some time to explore the best solution.

Thanks again.

Rick

Donald Corenman, MD, DC
Moderator

July 6, 2012 at 4:00 am

Post count: 8660

#6488

According to the radiologist, the cord appears normal. Injury typically appears as a “white” signal in the normal appearance of the cord. The physical examination also would note changes called “long tract signs” including hyperreflexia, Hoffman’s sign, clonus and sensory changes.

It is hard to know over the internet if you are doing damage to the cord but if the examination did not reveal those signs and the radiologist did not note signal change in the cord, the chances of injury at this point are not high.

The wait time for new patients is somewhat longer than 2 weeks but call the office and tell them we have conversed over the Forum and they will get you in.

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.

whatthe2
Member

July 6, 2012 at 4:22 am

Post count: 8

#6490

Understood, it’s definitely hard to say anything for certain corresponding over the Internet, but the information you have provided, along with what I have read on your website definitely makes me feel better about waiting to see you.

I’ve left a message with your assistance to schedule a visit. I look forward to seeing you soon.

Thanks again.

Rick

whatthe2
Member

July 8, 2012 at 6:35 am

Post count: 8

#6491

Hi Dr. Corenman,

I’ve got an appointment to see you on Aug. 23. I’m wondering if I can ask one last favor of you prior to my visit? My wife is somewhat freaking out at waiting that long since the last surgeon we saw said I should be in surgery pretty much immediately because in his opinion, “you are doing damage to your spinal cord right now”. I’ve been in severe pain since January, so a bit longer doesn’t bother me, but if I can ease my wifes concerns and assure her that I’m ok to wait to see you, we sure would appreciate it.

I’ve copied images from my MRI and posted them on Google Docs (no download necessary, so risk of virus). I’m hoping that the pictures will further your opinion that chances of injury at this point are not high. Again, I know it’s not the full exam needed to say for sure, but maybe they can be useful.

Thanks again.

Rick
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Donald Corenman, MD, DC

Average rating:

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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