8 months post microdiscectomy, I still have sciatica

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michael
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December 13, 2013 at 11:14 pm

Post count: 7

#9943

Dr. Corenman:

I have posted several times on your forum and now I’m at a loss of how to proceed. I had a microdiscectomy on April 15th of 2013 at L4/L5 for sciatic pain mostly in my left leg. The pain would be around 75% left leg/buttocks/foot and 25% in the lower right leg/foot. I would also have some very lower back pain as well (the back pain is very centralized). All these symptoms would be almost always present when I sit. When I get up to walk or stand, I’d get almost full relief. Same with lying down. I gained some relief of my pre surgery symptoms from the surgery, however, I still have enough pain to keep me from returning to work. That’s my issue. I’m an airline pilot for a major airline and I need to have to the ability to sit for 6-10 hours a day. I can get about 2 hours max before I have to get up and walk around for a while or go lie down for relief (impossible with my career). As of right now, my career is sidelined and I’m only 40 years old.

My current surgeon in Houston has said the next step is fusion at L4/L5. However, I have looked at my MRI’s and know that both L4/L5 disc and L5/S1 disc are both degenerative. So I am concerned he may be overlooking the L5/S1 disc area for some of the contributed pain. I’d hate to go for a 1 level fusion if, in fact, I needed a 2 level fusion. I need to get my career back on track if at all possible. Would you be willing to look at my MRI and give me your professional opinion? I can mail you the disc and pay whatever you charge for your time.

Again, almost all my pain is caused by sitting especially for long periods of time. I’ll have buttock, leg, foot pain in the left leg and mostly just foot pain in the right. Along with low central back pain. Once I stand up and walk around I will get almost full relief within minutes and same with lying down. I stay fairly active and busy it’s just that I cannot sit for any length of time.

Thank you.

Michael
Houston, TX

Donald Corenman, MD, DC
Moderator

December 15, 2013 at 7:11 am

Post count: 8660

#9948

You have to break all the symptoms down as to causation and then develop a surgical treatment plan.

By your history, you have had a microdiscetomy at L4-5 with what I assume is a left sided approach. Since you also have right sided pain, did you have a bilateral microdisectomy or just left-sided? Did the right-sided pain occur after surgery or did it not change (present prior to surgery but unaffected)?

Typically, buttocks and leg pain has an origin of nerve root compression but there can be other origins. Did you have a work-up prior to surgery to determine the source of this pain? How did this pain change since surgery?

You note that you have some lower back pain but do not note the intensity of this pain. What is the percentage of lower back pain as an overall total with leg pain? 30% lower back vs. 70% leg pain for example. If you had elimination of just the leg pain, could you live with the current intensity of lower back pain?

You note that sitting creates the pain and that standing reduces the pain. This is obviously not great for being an airline pilot but brings up some questions. Is the pain increased in your legs and back or only legs? Is your leg pain the limiting factor for sitting or is your back pain also a big issue?

Sitting leg pain increase generally indicates a herniated disc issue. Did you have a repeat MRI after surgery to determine the current status of your nerve root? Has this fusion been recommended due to other factors (vertebral slip, unilateral collapse or lower back pain) or is this a recommendation as “there is nothing left to do” but fusion?

Fusion is used for back pain issues or instability (slip or lateral collapse). By the sounds of your complaints, I do not assume that lower back pain is the majority complaint. There is much that still needs to discovered before a fusion is considered.

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.

michael
Member

December 16, 2013 at 3:06 am

Post count: 7

#9953

Dr. Corenman,

I saw 5 different surgeons about my back issues once they began in early 2011. All of them wanted to do conservative therapy which I can appreciate. This included PT, home excerise, and 3 rounds of steroid injections. None of those treatments helped me at all. However, due to the nature of my job (airline pilot) I have to be able to sit in order to perform my job, I continued to stress to them that if there was something we could do to help, we needed to do that. Most didn’t seem to really understand that I need to be able to sit. So the doctor that did my microdisectomy didn’t do any “work up” on where the pain was coming from, he just went off of my history of conservative therapy and symptoms and suggested the microdiscectomy. I was desperate and allowed him to do the surgery.

I got a some relief of some of the symptoms from that surgery, but not much. I am NOT worse than I was before surgery. That’s good! However, I will try to explain as best as possible my symptoms and intensity and such for you:

The back pain that I have is very low and it’s intensity can be just as unbearable as the sciatica at times. A lot of times it depends on the type of chair I’m sitting on. For example, if I go to a high school football game and sit on the bleachers, I am absolutely miserable with back and sciatic pain (mostly with the left leg). I have to repeatedly stand and walk around to get relief in a matter of 10 minutes. If I am driving my Ford F150 platinum truck, the seats are very comfortable and I can last a good 1.5-2 hours…however I will still have some pain, but it’s bearable until about the 2 hour mark then I need to get out and walk around. The pilots’ seats in the 737 are not comfortable at all and I can last about an hour before I have to stand to get relief, hence why I am not working. I have noted that I have some pain in the right lower leg and foot and that was always present even before surgery.

Once again, standing and lying down give me almost complete relief. Every night I go to bed I have almost zero pain in the back or sciatic nerve(s) once I’m lying down. It’s the sitting that does it for me. I had a repeat MRI at that end of July.

I mentioned earlier that I have seen 5 surgeons hoping to solve this issue. I have received 5 different answers from each one which is not very comforting. One said I had spondylolisthesis at L5/S1 (all the other surgeons said no I didn’t). Another said I’d need a two level TLIF from L4-S1 as those two discs are very degenerative and have lost height thus causing the foramans to close down on the nerve root exiting. Another said an ALIF for L5/S1 but said a 2 level fusion would be “too much surgery” for me. My last surgeon recommended the microdiscectomy as he said the L4/L5 disc had a small central bulge (which was true I saw it on the MRI). I went with him as I was desperate for something to help me get better. None of the doctors did any work up on where the pain was coming from. No discograms or anything. They just all went off my symptoms.

As you can see I am getting so many mixed answers. What’s a person like me, who isn’t a surgeon, to do with all those mixed answers??? One thing is for certain, my livelihood and career are basically over unless there is a real solution. You seem to much more methodical with your knowledge than anyone else, hence why I am seeking your opinion. I will gladly pay you to review my MRI and give me your professional opinion on how you would approach treating me.

Thank you again.

Donald Corenman, MD, DC
Moderator

December 16, 2013 at 10:04 am

Post count: 8660

#9954

Symptoms need to be broken down into pain generators. Surgery cannot be contemplated unless these pain generators are identified. Symptoms generally have certain causes that can be discerned by the activity that induces these symptoms. This is the first way to identify pain generators.

Your complaints of lower back pain generally would be discogenic in origin. Loading the disc occurs with flexion. Flexion includes sitting. Flexion also irritates nerve roots that are compressed with disc hernations. This means sitting will also cause leg pain in the case of a disc herniation.

Part of sitting has to do with the torso-hip angle. The higher the seat (pickup truck) reduces this angle. Sitting on a low chair (bleachers or pilots seat with the use of ailerons upon takeoff or landing) will increase this angle. This increase in angle in turn also increases discal pressure and lower back pain.

One simple trick that can help indicate the presence of discogenic pain is standing with extension (slight bending backwards) after the onset of lower back pain. This action unloads the disc (it loads the facets) and after a short period of time will give some lower back pain relief.

You do not have a consistent diagnosis. You do not have a diagnosis of foraminal stenosis. Foraminal stenosis would cause leg pain with standing and would be relieved with sitting, the opposite of your symptoms.

Most likely you have degenerative disc disease and possibly IDR (isolated disc resorption)-see the section regarding causes of lower back pain. The workup includes a thorough history and physical examination, review of all images, possible CT scan (if there is any doubt of the presence or absence of spondylolisthesis) and possible confirmatory tests (discograms or selective nerve root blocks).

I have a special relationship with some of the airline companies so you might ask your medical director as there is a more direct way to send films. I also have a fondness for pilots as I am currently getting my PPL. If your airline does not have this relationship- simply call the office, explain our conversation to my nurses and send your films by FedEx.

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.
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Donald Corenman, MD, DC

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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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