[Yakov]

#10836

Hi Dr. Corenman:

Two years ago I was rear ended in a 3 car accident. Initially, I sustained a back sprain. Within just 3 months, walking short distances became painful and I was weak on my left side. I left an active job and had pt, chiropractic work, and 2 spinal epidurals with minimal relief and 1 spinal nerve block at s-1 within the past month. The nerve block definitely helped calmed down the extreme nerve pain I felt all the way down my left leg to my toes and pain into my right thigh.

Imaging showed extreme facet arthropophy and stenosis in l4-l5 and more so in l5-s1. There are 3 disc bulges starting above l4 going down. An x-ray showed 5% spondololythesis at l5-s1 (didn’t know that word before!). I never had any history of back problems! That’s why I didn’t think there was nothing more going on in the ER and did not have any imaging done at the time. About six months later, I had cardiac stents implanted which cancelled a scheduled fusion surgery. Since I was forced to live with the pain, I have become to used to living with the pain.

I will be 2 years out from having the stents in the fall. Two surgeons recommended fusion.

I have become completely handicapped from this and am nowhere near the activity level I used to be. Being only 45, I want to have things the way they were before the acccident, but everyone tells me how possible it is to be in as much pain after a surgery.

Am I a surgical risk given my heart history? What other surgical options might be available to me?

Thanks very much for your time and advice.

[Donald Corenman, MD, DC]

#10866

Stent placement is designed to reduce your risk of heart stress that can lead to a heart attack. If you have not developed any further artery plaque and your heart is strong, there is no need to have undue concern regarding your heart.

With your history, your surgeon might consider a nuclear stress test to determine the health of your heart.

I have many patients who have undergone stent placement and do just fine in spine surgery.

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.

[Yakov]

#10875

Thanks for clarifying that Dr. Corenman. Now with that, may I present you the findings of an CAT scan and MRI to get your comments?

In November 2012– an XRAY of the lumbar spine showed 5mm grade 1 spondolythesis at l5 on s1. There are small osteophytes noted at t12-l1 and l1-l2.

In December 2012, an MRI of the Lumbar showed the following:

L3-L4, L2-L3, L1-L2- no significant disc protrusion or formanial stenosis.

L4-L5- There is moderate facet arthritis seen. Mild to moderate bilateral neural foraminal narrowing is seen due to disc bulge, facet disease and ligamentum flavum thickening.

L5-S1- Moderate to severe facet arthritis seen. Broad based disc bulge effaces the ventral aspect of the thecal sac. Disc dissecation is seen. Mild bilateral neural foraminal narrowing is seen to due to disc bulge, facet disease and ligamentum flavum thickening.

Impression: Spondolytic changes of the lumbar spine at l4-L5 where is disc bulge formation and acting in concert with facet disease and ligamentum flavum thickening to lead to mild-moderate neural foraminal narrowing at L4-L5.
2. There is subtle anterolisthesis of L5-S1 due to facet arthropathy.
3. No acute lumbar compression fracture deformity, or abnormal fluid collection or mass collection with the lumbar spine canal is appreciated.

In May 2013, I had at CT scan of the lumbar:

L1-L2, L2-L3, and L3-L4- mild hypertrophic facets and ligamentum flavum. Possible minor disc bulge. No significant spinal stenosis.

L4-L5- Disc bulge and mild hypertrophic facets and ligamentum flavum. These produce bilateral moderate foraminal stenosis. Central canal is borderline in size.

L5-S1- Promninent disko-osteophytic bulge and extensive bilateral vacuum facet arthopathy. These produce mild central and severe bilateral formainal stenosis, worse on the right.

Impression: Lumbosacral degenerative disc disease and worse in the lower lumbar spine.

2. Disc bulge and hypertrophic arthropathy at l4-l5 and l5-s1.
Resultant moderate bilateral formaninal stenosis at l4-l5, and mild central and severe bilateral foraminal stenosis at l5-s1.

In October of 2013, I had an MRI. I thought I would be having surgery in a few weeks, and this was done for an update:

l1-l2, l2-l3, l3-l4- Minor disc bulge. Hypertrophic facets and ligamentum flavum. No significant spinal stenosis.

l4-l5- Disc bulge with a mild left foraminal disc protrusion. Borderline right and mild left foraminal stenosis.

l5-s1- Substantial hypertophic facets. MInor disc bulge. These produce bilateral moderate foraminal stenosis, worse on the right.

Impressions:

1. Lumbosacral degenerative disc disease.
2. Disc bulge with a mild left foraminal disc protrusion at l4-l5. Mild left foraminal stenosis.
3. Hypertrophic arthropathy and a minimal disc bulge at l5-s1. Bilateral moderate foraminal stenosis.

I had an EMG done in January 2013 which showed acute denervation in left mid lumbar roots and acute left lumbar radiculopathy mainly l4-l5.

I have had 2 spinal injections which did not give me any relief. But just a few months ago, I had a nerve root block at s1. This has calmed down the nerve significantly. Whereas pain was a 7-8. It has lowered it to 4-5. Have to be thankful for such improvements. But I still experience plenty of pain and weakness.

Now in analyzing the spinal changes, what I see are the mention of a disc bulge higher up and mild stenosis at l4-l5, which is not seen in the MRI in December 2012.

Given these findings, what procedure would be best to correct these issues? I am very concerned that one back surgery would or could lead to another down the road. It has been suggested by 2 surgeons that I have fusion. One suggested ALIF and one suggested PLIF. What I have heard regarding fusion is that although it stabilizes that area, it causes the other levels to break down in years to come requiring another surgery.

If I would have fusion, I’m not sure if I’m correct in my feeling that ALIF is better because it does not disturb the back muscles which has been suggested to help in preventing destabilazation of the spine at other levels in the future. I have heard it’s an easier recovery than PLIF. Although, the advantage to PLIF is that the nerve roots are easier to see and correct. But I have been assured the same is possible with ALIF. One downside to ALIF, is that it works better only on one level not more. That later results show stenosis at l4-l5, is ALIF an option? I look forward to hearing your thoughts.

What has been so remarkable to me Doctor Corenman, is that I never had any back issues prior to this. I was involved in 3 car crash in April 2012, resulting in us being rear ended. Besides for stiffness and a back sprain, I made nothing much of it until 3 months later, while dealing more achiness and stiffness than I ever experienced, it became difficult and painful to walk. Not long after I had to get a cane. And within a few months I was unable to walk more than a block without a wheelchair. I do get around and usually after an active day, I am in excruciating pain at night. I take some pain medication and sometimes wake up feeling better in the morning, and sometimes the pain lingers.

If this needs to be fixed surgically, what can give me the best possible outcome to be thriving and active as I am only 45?

Thank you so much for your time and direction.

[Yakov]

#11008

Dr. Corenman, I would be most grateful for your feedback and wisdom on how I should proceed. Thanks so much.

[Donald Corenman, MD, DC]

#11009

We will first start with the preexisting disorders in your lumbar spine prior to your accident. Most likely, you had degenerative changes of your lumbar spine that were asymptomatic prior to your accident. You might not have had any symptoms after your motor vehicle accident if not for the presence of these degenerative changes.

Now to your current symptoms. You see to have two degenerative spondylolistheses at L4-5 and L5-S1 with foraminal stenosis at each level. In my opinion, this would call for a TLIF at both levels (a two level PLIF would suffice).

Anterior fusions (ALIFs) might work for one level but not two. In addition, ALIF surgeries have more potential complications, especially in males. Finally, the decompression of the nerve roots is indirect. This means that you open up the disc space and spread it which should give the nerve root more room. You cannot visualize this opening so it is called indirect.

TLIF or PLIF fusions do not disturb any important back muscles (the erector spinae muscles). These surgeries do move or remove the small segment to segment muscles (multifidi and rotators) but these muscles will be useless in the face of a fusion anyway. Why some individuals advertise preservation of these muscles when they will have no use or function after surgery is beyond me.

There is a chance that fusion can increase the stress of the level above but doing nothing can also cause increased stress. There is probably little motion of these two degenerative levels now which currently increases the stress at L3-4. Fusing these levels might increase the stress a little more but not significantly in my opinion compared to right now.

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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