ACDF, PCDF (+ Atlas Cable) and ADR

Tagged: Failed cervical spine surgery

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Neurogenic
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July 11, 2017 at 5:07 pm

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#25498

Good day Dr. Corenman.

I would appreciate some assistance in a “4th” opinion.

A little history, I was involved in a motor vehicle accident where I was rear-ended in 2002. I progressively started having severe neck pain, headaches nearly daily and pins and needles in my arms (bilateral), so I saw my Neurosurgeon 2004 whom recommended that I have a discogram first to see where the problem is.

I was then diagnosed with a disc herniation at C4-C5 and was taken to theatre to have an ACDF of this level. For sometime it was going well until the beginning of 2006 when the pain and pins and needles came back and after a second discogram the results showed a C5-C6 rupture and again, the neurosurgeon said that he would need to go in anteriorly to revise the C4-C5 and do a full C4-C7 to stabilise. Unfortunately my body rejected the titanium so 6 months later I landed up in theatre again, but this time for a posterior atlas cable from C4-T1 which seemed to help and had to have the anterior failed points cemented posteriorly whilst I was open.

In keeping (in all his treatment plans and instructions), I went for regular physiotherapy (at least 2 sessions a month) it all went well until 2009. again, the headaches, pins and needles into both my arms came back with changes to sensation decrease in the left hand and especially the pinky finger. Although the surgeon did say that the posterior instrumentation had done its job and could theoretically be removed, he advised against it as the level C3-C4 has collapsed. The surgeon had then advised that if the pain was really bad (which I am a wimp when it comes to pain and very concerned with loss of use of my hands especially seen as I am a paramedic) he advised that a final surgical intervention was required where he would do a C3-C4 ADR. He was the only Neurosurgeon at the time who had been abroad for training and practical work on doing ADR’s.

I had the ADR done and was home 3 days later and things never went well afterwards. unfortunately my original Neurosurgeon had suffered 2 x CVA’s and then retired. The new Neurosurgeon has been treating me for the last 7 years with severe headaches, pins and needles, numbness, loss of strength in my left hand (more of then the right hand) and I at times have problems distinguishing if I have an earache or if the pain is from the neck. I have had infiltrations with numerous rhyzotomies over a period of 5 years now without any relief. Radiology results with MRI and AP checks confirmed that (as of two years ago) that the C3-C4 ADR was still working and that there was no issues at the level.

I then opted to see another Neurosurgeon recently (because the 2nd had only assessed me once in all the years and he cannot read the consultation notes of my 1st neuro but can read all of the surgical notes) and had follow up radiology investigations which showed a +/-11% compression at the C3-C4 level by means of Nerve Conductivity test. It has also now come to light that the ADR at C3-C4 level has fused and there is no movement at that level. All instrumentation in my neck is titanium and the AD is a pivot style joint without the gel sack or “shock absorber” type joint.

Questions:

1. What will happen to the C2-C3 level in a number of years (I am a 34yr old male with a BMI of 25)
2. Is it possible that the entire C3-C4 level has fused and if so, would a ACDF make any sense to be done seen as that level is already fused?
3. Continue physio at more frequent intervals?
4. Would it have taken a number of years for this fusion to take place at the ADR?
5. Will further rhyzotomies work on this issue?

My latest neurosurgeon has indicated that there is a general possibility that 60% of ADR fail (fuse/reject ratio).

I have had to give up my intended career because of my neck as I am deemed unfit to work on the road now.

I am just lost now on what next to do. Chiropractor option is not an option as where I stay, they are deemed (no offence to any Chiropractors at all) not the best suited treatment option. Orthopaedic surgeons are good for the bone damage but not working on the nerves itself (according to my 1st neuro at the time)

I have a really good flexion/extension and rather good rotation margin (compared to some patients that have limited movement after a single level)

2004 Feb – C4-C5 ACDF
2006 March – C5-C6 ACDF
2006 Oct – C4-T1 Posterior Atlas Cable
2009 Feb – C3-C4 ADR
Numerous rhyzotomies
Most recent was Occipital Block with C4-C6 Steriod injections (which seemed to help for a few days with no headaches but all started to come back now)

I appreciate your time and willingness to help on advice and to what to expect in the future with my neck.

Donald Corenman, MD, DC
Moderator

July 11, 2017 at 7:42 pm

Post count: 8660

#25499

You don’t state if the discogram results during the 2004 neurosurgeon period. You then had an ACDF of C4-5 and did “well” for 2 years.You then had return of pain and paresthesias (“pain and pins and needles came back and after a second discogram the results showed a C5-C6 rupture”). I am unclear why a discogram was needed as with paresthesias present, there had to be a nerve root compression which should be obvious by MRI. Nonetheless, this surgeon found that you had a pseudoarthrosis (lack of fusion) of C4-5 (“he would need to go in anteriorly to revise the C4-C5 and do a full C4-C7 to stabilize”). In addition, why you needed an additional level fused at C6-7 (remember that the new data from the discogram noted a ‘C5-6 rupture'”) is not understood.

Your body did not “reject the titanium” as I have seen only one case of titanium allergy in 8000 cases and there was no rejection. You simply had another round of pseudoarthrosis (maybe multiple levels) and he had to go posteriorly to fix this problem. Atlas cables are simple devices to restrain motion and with posterior bone graft, should do the trick to fuse these non-fused segments. Why he had to add C7-T1 to this fusion is another mystery in your case.

You then note that C3-4 broke down and he wanted to perform an ADR (artificial disc replacement). I would be somewhat cautious about an ADR above a 4 level fusion unless your activity level is not too high (you don’t run, play tennis, ski significantly or mountain bike). You then developed a fusion of the ADR through hetertopic bone formation (bone that forms in places it shouldn’t).

If you have a fusion of C3-T1, this increases stress on C2-3 and this level can wear out. You cannot tell if there is a full vertebral C3-4 bone to bone fusion without a fine-cut CT scan. If this has not been performed, this is the next step. If C3-4 is truly fully fused with structural bone, then this level should not cause pain. You might not have a solid fusion but some bone spur that crosses and impedes the motion but does not fuse. What is the condition of the facets at this level? The ADR will take months to years to fuse as bone has to cross in areas that are not designed to support bone growth.

The statement; “there is a general possibility that 60% of ADR fail” makes no sense. It is either fused or not fused.

Chiropractors would be contraindicated for your condition.

The statement “Orthopaedic surgeons are good for the bone damage but not working on the nerves itself (according to my 1st neurosurgeon at the time)” is a fallacy as I work on nerve root every day and have a great record of nerve pain relief. In addition, remember that the neurosurgeons were the first to work on you and failed with every surgery.

You need to find a spine surgeon (fellowship trained orthopedic spine surgeon) an opportunity to evaluate your case and determine what is going on.

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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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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