Back pain after microdiscectomy

Tagged: microdiscectomy and lower back pain after, possible SI joint syndrome

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Donald Corenman, MD, DC
Moderator

March 9, 2017 at 5:44 am

Post count: 8660

#24477

These motion reducing systems are not designed well. They restrict through fixation by the base of the construct-the pedicle screw. This means that the fixation occurs posterior to the facet (where the rod attaches to the screw) which is not natural and places undo pressure on screw fixation. Since the center of rotation is changed to the back of the spine due to the fixation point, the motion is now off and the screw stress can loosen the fixation (the screw cavities in the bone).

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.

Michaelrch
Participant

March 10, 2017 at 1:56 pm

Post count: 19

#24490

Thanks again for your advice Dr Corenman. I will bear that in mind.

Re the Neurolysis which I am scheduled for in April, I understand the chances of success are 50-60%. I asked my surgeon if the op could result in worse pain afterwards if the scar comes back worse. He said that it is not likely. He also intends to use Medtronic Medishield (marketed in the US as Oxiplex) and this has a good track record of reducing incindence of adhesions.

In your experience with your patients, if the neurolysis op does not work, is there a serious chance of the symptoms being significantly worse? Also do you use gel barriers in your practice and if so, how do they work?

Many thanks again as always
Michael

Donald Corenman, MD, DC
Moderator

March 12, 2017 at 6:55 am

Post count: 8660

#24498

Medishield is composed of carboxymethylcellulose/polyethylene oxide (CMC/PEO) gel. It is designed to be non-reactive to prevent WBCs and then fibroblasts to migrate to the surgical area and prevent scar. I have not used this material and it might be OK to use. I have one concern and that is that prevention of scar formation is important but if this material also prevents the annular tear (the original hole in the disc) from scarring, this might lead to more recurrent hernations.

I use AmnioFix®, a composite amniotic tissue membrane minimally manipulated to protect the collagen matrix and its natural properties. This is a “sheet” of material that lies directly on the nerve root to prevent adhesions. Does it work? I have only been back to revisit one nerve root that I have operated on and there were no significant adhesions but this is not an endorsement of Amniofix. The success rate is still 50%.

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.

Michaelrch
Participant

March 12, 2017 at 7:16 am

Post count: 19

#24499

Many thanks again Dr Corenman

Re the gel barrier, as I had the microdiscectomy 9 months ago I hope that the tear in the annulus should have scarred over now. The main aim of this next op is to clear the nerve of scar tissue and any debris that is in there but is not clear in the MRI. That said I suppose if the surgeon thinks that he needs to trim a few millimetres of the disc he might do. He does think that the problem is the combination of the fixed nerve and a very small bulge in the disc.

Re the neurolysis, in your experience is there a significant chance that the symptoms of the scarring after this op will be worse than what I have now?

I know it’s not a good reference source given the bias and self selecting group of people, but I have read reports on forums of people having an op to remove scar tissue and being in worse pain afterwards. I am hoping that they are not representative and that the gel or barrier can reduce these risks to an acceptable level.

Donald Corenman, MD, DC
Moderator

March 12, 2017 at 9:47 am

Post count: 8660

#24502

If there is continued compression of the nerve root, even by a small disc herniation, the chance of recovery is much greater than 50% with redo decompression. This is because the scar tethers the nerve root preventing it from “moving out of the way” of the new but smaller herniation. Removal of the scar and the herniation should have as high as 85% success rate (depending upon the size of the new HNP).

Scarring will occur anew and surgery generally does not decrease the scar volume but with the agent your surgeon will use (Medishield) as with the one I use (Amniofix), there is the possibility of reduced scar.

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.

Michaelrch
Participant

November 23, 2017 at 11:49 am

Post count: 19

#26905

Dear Dr Corenman
It has been a while so here is an update on where I am up to. Not great.
After some discussion the surgeon concluded that the best option would be a dynamic stabilisation, and due some arthritis of the L4-L5 facet joints, he wanted to do S1-L4. So this is what we did in May 2017. After opening me up he found that the facet joints were very enlarged (although this had always been asymptomatic). At first follow up he was very pleased with the placement and fixation of all 6 screws but I was getting leg pain and pain in my lower back. This turned out to be SI joint pain and then pseudo radicular pain from the inflammation. Then I also started getting a similar problem in my left L5S1 facet joint, I have had numerous steroid injections into the SI joint, facet joint and L5 nerve which all help a bit but nothing works for more than a few days. I am mostly bed bound and on 15mg Targin, 600mg Lodine and 4.5mg Lexintanil a day. I am getting pain in my SI joint, fact joint and plenty of nerve pain in the leg after waklking, sitting etc. So all worse than before.

After discussion with my physio, we have a theory why my recovery is so bad. He has found (and this agrees with past experience) that my whole lumbar spine is VERY VERY stiff. When I was fit and healthy, m6 wife (a yoga teacher) had commented hat when I bent forward to touch my toes, my L5S1 joint was mobile, then my lower back was straight and rigid and would only start arching above L1.
So my physio’s theory is that because my L4-L1 is completely rigid, then my back is behaving like I am stabilised/fused from S1 up to L1, and maybe even a bit into my thoracic spine. So this is hugely overloading my SI joint and my L5S1 facet joints (due to the slightly changed geometry at that joint after the stabilisation)

Do you agree that this “natural” stiffness in L4-L1 or even up to T11/T10 could be he reason why I have recovered so badly from the original microdiscectomy and now this stabilisation? Ie after the microdiscectomy the L5S1 was badly overloaded so no amount of physio would allow me to stabilise it with my muscles. Now that S1-L4 is stabilised, then the overloading is going into my SI joint and so that is failing now. Does that make sense? If so, what treatment is possible to relieve this chronic tightness in these other segments?
If not, what would you suggest I should try?

My surgeon did previously mutter that fusion might have to be the next step but it strikes me that that could only make things much worse!

I very much look forward to hearing your advice.
Many thanks as always
Michael

PS the stabilisation system I had installed is this one
http://www.spinesave.com/system-iv/
The screws look well placed and integrated so far. There is no sign of loosening on X-rays or CT scans. I have the most flexible rods that should allow up to 50% motion in the joint.
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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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