40year old with 80 year old back

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texasspondy
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December 27, 2011 at 8:34 am

Post count: 25

#5262

Hi Dr. Corenman. First off, I’d like to say, I’ve seen a number of youtube videos where you explained how to look at an xray or mri, and I was impressed by your detail, patience, and energy you put forth. Thanks, I’ve enjoyed those.
Onto my questions, first, my Mris
2008…Transitional vertebrae at lumbosacral junction labeled s1. With rudimentary s1-s2 disk.
Subtile disk desiccation without disk space reduction involving lumbar intevertabral disks.
Mid curvature of lumbar spine convexity leftward.
L1-l2 through L4-5 do not show significant posterior disk bulge, protrustion or hernation or central canal or foraminal stenosis, however there is mild facet arthrosis bilaterally at l4-5.
At l5-S1, there is bilateral L5 spondylolysis without spondylolisthesis of l5-S1. There is minimal 1-2mm posterior broad based disk bulge slightly indenting ventral thecal sac without mass effect on s1 roots or sleeves. There is facet arthrosis. No central can stenosis. Mild inferior foraminal disk bulge and spondylolysis seen with mild bilateral foraminal narrowing. Also large hemangioma involving l5 vetebral body without vertebral body collapse. No paraspinal soft tissue mass seen.
Sep2011 MRI…
Hemangioma of the L5 vertebral body seen. No scoliosis, normal lordosis. No compression fractures t12-s2. Disc space, foramina and spinal canal of L1-L2 through L4-L5, no abnormalties.
L5-S1 shows bilateral pars defects at L5, without spondylolisthesis. Mild asymmetric left disc bulge and left facet hypertrophy result in mild left foraminal stenosis. The spinal canal is patent.

I’ve had off and on little mild flareups in low left back, always on the left side near the si joint area, for the last 10 years. The last few months, it is not a flare up, it stays all the time now. I have done 3 months of P/T now. Saw a neurosurgeon 3 months ago, nice fella. He gave me 2 trigger point injections in low back muscles, put me in a corset for 6 weeks. I stretch every day, and do back/stomach/abdominal p/t 5 days a week. I can’t seem to get any better here. Some days pain is just manageable, 1-2, other days it’s 3-5. I’m afraid to bend over or bend backwards, Lumbar section seems tight.
Not sure what kind of course of action is next, epidural injection or facet joint injection? I’m afraid my future is very bleak with this condition. I’m guessing the stenosis is what is causing discomfort, maybe the facet joints, don’t know. I dread the though of major back surgery, I’m guessing with bad facet joints a fusion is in my future, but how many levels. How would you fuse a hemangioma vertebra, wouldn’t that be like drilling into sponge cake and the anchors would pull right out.
I would very hard to maintain what I have, I feel like my back is like a house of cards, with a crumbly foundation, it’s just a matter of time? I’m a mechanic, I use to golf, and ski, these feel like things of a long ago past. Your interpretation if I walked into your office with this mri, and what my future holds? Thanks Doctor

texasspondy
Member

December 29, 2011 at 6:47 am

Post count: 25

#5277

I should also add some information I note that you mention in a number of other posts. I really can’t say I have leg or foot pain/tingling. It’s mainly left low back/si/QL area. I do have couple lipomas (so I’m told) around this L5 area that feel sometimes bruised from sitting but I’m guessing that’s referral pain. Honestly sitting seems to aggrivate it worse. Walking feels better, and just standing doesn’t seem to aggrivate it as bad. My P/T generally makes it feel less aggrivated but that’s usually short lived.
I actually yesterday purchased your new book, I don’t expect my symptoms go away with your book, but maybe I can get an even better visual as to what is happening when. One of my biggest dilemmas with this problem is knowing how to do the correct excercises to not aggrivate it. My P/T folks gave me a number of things for core work, I’ve worked on that 3 months now. My chiropractor took a couple things out, said he didn’t like em and added a couple other things (superman and back extension raises 30deg only), then I read online superman is the worst thing one can do for foramen problems. It so frustrating to know what to do and not with all the information out there. The neurosurgeon said yoga was great and really only prohibited me from squats and axially loading the spine from above the shoulders.

Donald Corenman, MD, DC
Moderator

December 30, 2011 at 1:56 am

Post count: 8660

#5280

Your symptoms are 10 years’ worth of left SI region pain, intensity about 1-5 (0-10 VAS scale) depending upon the day and increasing in consistency over time. You have no leg symptoms. Your trade is that of a mechanic and your back feels fragile. Sitting increases symptoms and walking decreases them.

The diagnosis needs to correlate the MRI findings with your symptoms. X-rays are valuable in your case as with pars fractures and degenerative facet disease noted on the MRI, you could have developed a spondylolisthesis. Standing views with flexion and extension films are needed to look for slip and instability. Now for the MRI.

Your main problem is the pars fractures and slip (isthmic spondylolisthesis) at L5-S1. The reason you have no leg pain or paresthesias is that you have no nerve compression as identified by the MRI. I imagine you have moderate degenerative disc disease of L5-S1 but this is not noted on MRI.

Rehabilitation for isthmic spondylolisthesis involves a flat back posture program. You should not do extension exercises as this will aggravate pars fractures. Any yoga position that causes bending backwards should be avoided and in general, you want your lower back to become stiffer. Manipulation of the L5-S1 level should be avoided.

If rehab and injection therapy does not help, this problem is most likely surgically treatable.

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.

texasspondy
Member

December 31, 2011 at 8:08 pm

Post count: 25

#5287

Thank you Doctor for your response and information.
I am suppose to see the neurologist again on the 10th and I’m going to see what would be the next step for me. I would assume a epidural injection since I have had the trigger point injection already.

I am also going to ask him, since I do not have an xray, if he could request one for me including bending and flexion, if I understand you correctly.

Also thank you for the flat back program visual. I kind of thought that too but my chiropractor has said adjustments and bending over stretches were to get new blood to the area for healing. My thought is the more I take adjustments in the l5 area and any bending there, is retearing the fracture fibers.

As to surjical, which sooner or later, I would gather could be my outcome. Are you referring to a TLIF for this condition? If so, can my l5 vertebral hemangioma be fused? I don’t know enough about it, but the theory scares me that tumorous bone couldn’t withstand a fusion. Again, thanks for your time.

Donald Corenman, MD, DC
Moderator

January 1, 2012 at 3:05 am

Post count: 8660

#5288

If you end up with a fusion at L5-S1, the TLIF procedure is the one that is most likely to be used. A normal hemangioma is not a factor in a fusion. These are quite common and typically ignored with treatment.

You are correct that no extension of the back should be employed with rehabilitation. Extension will tear or at least aggravate the pars fracture pannus.

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.

texasspondy
Member

February 12, 2012 at 1:35 am

Post count: 25

#5555

Hi Dr. Corenman. Since I last replied, I had an office visit with my neurosurgeons PA. Very nice guy and seemed very informative as well to my questions.
He was pleased and impressed I had done much research on my condition and was asking questions, he said he wished more patients did so.
Anyrate, as we talked he did mention one thing which I found interesting/confusing.
In the topic of when does one decide to have surgery, I said to him I will deal with it as long as I can tolerate the pain/symptoms conservatively, and when I can’t bear it any more, I will give in to surgery. He responded with, you really should consider having surgery when or if your quality of life has degraded to a point that you no longer enjoy much of the things you use to enjoy, so have surgery to give yourself a quality of life back.
Then he said, you should not have surgery due to pain, because we can give you quality of life back, but can’t guarantee pain removal. I guess I thought they went hand in hand but it kind of took the wind out of my sails, your thoughts??

He was all for setting up a Epidural spinal injection with a Pain Management Specialist. So they referred me to a doctor. I got into see him and he had my images and report. He also did a few tests of holding my hips and having me try to bend over to touch my toes (which was poor and difficult) benc back (which was easy), and try to turn to the sides, he concluded that he felt my spondy had not slipped yet, there was enough holding things in place, and has me scheduled for next wed a epidural I believe around the area of minor disk bulge L5 and one or two other nearby locations.
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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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