5 months TLIF L5S1

Tagged: 20% per week rule, Early motion after lumbar fusion

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jericho163
Participant

March 31, 2016 at 6:02 am

Post count: 19

#21810

Hello DR COrenman,

I had surgery on L5s1 Tlif 5 months ago. It was an open procedure.

The operation removed my mid spinal stiffness and pain and the disc area. However I still suffer from alot muscle tension and fatigue whenever i am sitting or standing.

My 3 months xray shows all hardware in place and I also showed the xray to another surgeon. He did comment that the 3week xray shows the bonegraft but the 3months one shows some of the bone graft is not there and he mentions resorbtion. Both my own surgeon and this surgeon says 3 months xray is still too early to see fusion growth. Should I be concerned.

I was cleared by my surgeon to go PT at the one month mark. I was doing stretches like a half child pose and also lying down and turning my legs to one side. In your view, does PT damage the fusion process if there is some bending and twisting involved(lying down).

Thanks

jericho163
Participant

April 2, 2016 at 1:48 am

Post count: 19

#21827

Hi DR Corenman,

Really appreciate if you can help me on this, thanks in advance!

Donald Corenman, MD, DC
Moderator

April 2, 2016 at 5:53 am

Post count: 8660

#21832

If there is no BMP used, the bone graft will appear to fade away before it fills in (on occasion). When bone graft is placed, the body absorbs the calcium off the graft leaving the protein matrix. Then the body builds a scaffolding of calcium back onto this matrix. The appearance of fading and then reappearing is typically what happens. At three months, the rebuilding should start occurring.

I am conservative for starting therapy. The first six weeks, I allow the patient to use an elliptical, stationary bike or a treadmill (walking). From six weeks to three months, PT starts but no bending, twisting or lifting more than 10-15 pounds. At three months, I start full range of motion.

Will early motion inhibit the fusion process? I can’t give an absolute answer but with the first three months critical to grow bone, I don’t allow my patients full range of motion. Due to that restriction and the use of BMP, I have about a 99% fusion rate.

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.

jericho163
Participant

April 2, 2016 at 6:32 am

Post count: 19

#21838

Thanks DR Corenman!

can i ask if spinal fusion is similar to long bone fracture healing… and heals via indirect bone healing.Is that right? And it heals via relative stability rather than absolute stability?

And second question, are muscular issues common 5 months post op? Some people seem to be more affected by the muscles cutting, am i right?

Donald Corenman, MD, DC
Moderator

April 2, 2016 at 7:24 am

Post count: 8660

#21839

Healing in both spine fusion and long bone fractures is essentially the same. The big time to heal is OJD (osteocyte jumping distance). In the long bone fracture, the osteocytes are about 3 mm gapped. The disc fusion is at least 6 mm. Bone heals at about 1-2 mm/month. This is why the posterolateral fusion heals faster than the intradiscal fusion.

Muscular issues can take some time to heal. It is not the “muscle cutting” (unless the surgeon used a very large incision) but the adaptation of the loss of motion of the fused segment that takes some time for the cerebellum to accommodate. Also, if you have been restricted in loading and motion, significant increased activity can cause insertional tendonosis (“tennis elbow of the back”). I use a rule called the “20% per week” rule.

If you were an olympic shot-putter, who would normally throw a #16 shot 75 feet, 100 times a day, I would cut everything in 1/2 and start there. That is, after a solid fusion, I would let him throw an #8 shot 35 feet and about 30 times per day to start. (This individual stated he could “spit” farther than that).

Any one parameter he could increase by 20% per week. That is, he could either increase the weight by #2, increase the distance by 7-10 feet or increase the number of throws from 30 to 36. Each week, one of the parameters can be increased. This keeps the stress on the ligaments and tendons down and prevents tearing of the insertions. You can increase faster but I am not sure if that is “too hard too fast”.

This rule can be adapted to the gym, cycling, golf, running or tennis.

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.

jericho163
Participant

April 2, 2016 at 7:39 am

Post count: 19

#21840

Thanks Dr Corenman,

Is amzing you give free advice to people like me!

May I ask one more question. Is it abnormal that at this stage I had issues sitting/standing long? Preop I had those issues as well, but somehow I knwo the surgery has worked because My mid spinal pain and stiffness is gone.

And assuming I fuse well and had no other structural issues, what is the best way forward for me at this point of time? Be patient and try to strengthen the lower back muscles. I do feel alot of weakness there. Or just take it easy and let time heal itself
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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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