assorted cervical questions

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exercise453
Member

December 18, 2012 at 2:04 am

Post count: 53

#7619

Hi Doctor,

I read the excellent thread on nerve injuries and recovery. Aside from the great technical education what struck me was your candor and use of “we just don’t know”. I have some questions and hope it is ok to ask a couple at a time.

I understand the timeline for recovery of a motor nerve but does that timeline apply to sensory symptoms. Specifically would you recommend any type surgery for classic symptoms of a non-motor c4 unilateral nerve root radiculopathy that you knew was compressed and symptomatic for seven years??? (or c3)

In a typical cervical epidural steroid injection in thru c7-t1 (vs snrb) for left side symptoms, would the medicine reach and benefit nerve roots (and discs) higher up like c4 and c3 (or even c2). Would there be benefit to “tilted left???

Thanks

Donald Corenman, MD, DC
Moderator

December 18, 2012 at 6:47 am

Post count: 8660

#7621

A sensory nerve injury is not as problematic in day to day activities as a motor nerve injury but the healing potential is about the same. Nonetheless, this is a preganglionic nerve (dendrite) and seems to questionably have a better chance to heal.

There is some evidence that the longer a nerve is compressed, the poorer chance it has to heal (within reason).

A steroid injection at C7-T1 will not reach the C3-4 level unless the bolus of liquid injected during the ESI or SNRB is very large and most injectionists will not do that for fear of a pressure injury.

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.

exercise453
Member

January 28, 2013 at 4:13 am

Post count: 53

#7838

Dear Doctor,

I did not understand your answer about surgery on a compressed c4 nerve root if you knew the compression was 7 years old and the symptoms debilitating. I tried to shape the question to be a yes-no answer and I did see your words within reason. I want to be absolutely certain of your opinion on this because I believe this to be one of my problems and its elimination might make a major difference. It may be the one thing something can be done about and the one thing I might be willing to do. I also believe it to be out in the foramen and I wonder what would happen if the nerve were decompressed. Way back on my c2-3 facet thread I mentioned that there was superb relief on a C3-4 block but a later radiofrequency failed. I cannot help but think the anesthetic may have dripped on the nerve root. I had two mri’s. The first shows some compression. (tesla 1.5). The second a year later unfortunately was an open mri and it is awful (didn’t know better at the time)…but there are some revealing axial cuts that show the disc at c3-4 sitting on 95% of that nerve like a boulder on an ant.

So…if this was a simple (for you) foraminotomy would you perform surgery if you knew it was a debilitating sensory c4 radiculopathy that was traumatically induced (weight lifting/fall while jogging) 7 years ago or is it simply too late for any rational hopes of recovery of that nerve???

No response necessary here. Thought you might find this interesting. We went back and forth on the c2-3 facet thread and also the cervical trigger point thread about “the thing” near c3-4 that I am always pressing and also some atrophy (prior to any radiofrequency). One doctor called it a calcification and your last words were puzzle. I think I know what it might be. I think it is a neuroma, one of the small posterior muscles innervated by c4 (longissumus or semispinalis capitus….or a muscle in that area). Am I paying attention or what. 

Thank you

Donald Corenman, MD, DC
Moderator

January 28, 2013 at 12:28 pm

Post count: 8660

#7841

The injury to a sensory nerve from a disc hernation is pre-ganglionic meaning the dendrite of the nerve is affected and not the axon of the nerve. See the nerve anatomy section to better explain this.

It is thought that the dendrite has a better healing ability than the axon does so that a sensory nerve injury has a better chance of recovery than a motor nerve root does.

Let us assume the compression of the nerve root is 7 years old and has been “stable’ for that seven years. If the injury “has already been done” over this long period of time, decompression of the nerve would not be as helpful. Nonetheless, if the nerve still generates pain, there could be some component of continuing injury that could be improved from a surgical decompression.

A “simple foraminotomy” can be helpful but it depends upon the location of the bony compression. If there is a large spur generated off the uncovertebral joint (located in the front of the spine), a posterior decompression will “open the nerve hole” so the nerve does not have constriction. The problem is that this procedure will not remove the spur that projects from this uncovertebral joint and the nerve, while not squeezed, will still be tented over this spur. This is why satisfaction from this procedure is generally not as high as an ACDF under these circumstances.

Probably the best test to determine if surgery can be helpful for you is a SNRB (see website). The problem with this test is it will anesthetize the nerve regardless if the origin of the nerve pain is from compression or from chronic injury.

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.

exercise453
Member

February 3, 2013 at 11:14 pm

Post count: 53

#7896

Dear Doctor,

We see a procedure called accurascope by one of these “spine centers”. A cervical procedure places dye and a thin wand into a herniated disc under fluoroscopy and a laser shrinks and seals the disc, shrinking the herniation off the nerve. They put on a band-aid and you go dancing (so to speak). It surely looks like the way things should be treated in the 21st century.

They do make a valid point in their literature where they claim to offer 30 treatments/procedures. They state that doctors diagnose whether the procedures they perform fits versus what is the very best or newest treatment out there. Sadly I believe this to be spot on.

What about this type of procedure to reach and eliminate some herniations as alternatives to acdf and foraminotomy??? Is it a viable alternative or is it flawed and steer clear in your TRUSTED opinion???

Thanks.

exercise453
Member

February 3, 2013 at 11:25 pm

Post count: 53

#7898

P.S.

Of course I do not believe this although I sure do want to. It sure would be nice!
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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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