Complex back injury question for Dr. Corenman

Tagged: degeneration, facet, L5S1, Spondylolisthesis

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ol99
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March 8, 2021 at 9:07 am

Post count: 14

#33705

Hi Doctor Corenman,

I (32M) have an issue that might be interesting to investigate.

Almost a year ago I injured my back while doing deadlifts – had mild, tolerable pain in the left buttock and back of the thigh.

9 months ago, while doing PT, I was lying on my stomach in maximum back hyperextension and pulled my left leg to the side of my body. Immediately I felt sharp pain in the right side of my low back (slightly latteral from the right S1 nerve root, maybe facet location).

A few days later my right leg, felt slightly numb/altered in sensation in the region from the knee to the foot. I did an MRI which showed a broad 6.5mm central-paracentral-foraminal left protrusion on L5S1, with isthmic spondylolisthesis, slight instability, bilateral pars defects, DDD, and an annular tear on the same level.

EMG showed compression on the left S1 nerve, and small radiculopathy on the right S1 and left L5.

I received a diagnostic nerve block in both S1 nerves. The left leg started feeling a lot better, while I felt no improvement in the right leg, and only felt minor improvement in the right side of my low back.

Eventually, 6 months later I started having muscle weakness in the left calf and had an endoscopic discectomy.

Now, 3 months later the left leg is much better, but there is almost no change in my right leg.

A new post-op MRI shows the same things as pre-op, just that the protrusion at L5S1 is smaller.

The pain I have originates from the right part of my low back (around the facet probably) and is focused in my right knee. If I try to do back extensions or try to hang from a pull-up bar, the pain increases in intensity and expands to my right foot.

If I try to do a quick flexion-extension movement, I get a lot of pain in the back of the right thigh.

If I try to side-bend to the right, I get pain in the small toe in the right foot (despite not having any herniation). This was true before and after the surgery.

I noticed that if I try to walk with my back flexed, all the pain goes away from my right leg, and I start to have a gait issue with the left one. Conversely, if I try to walk while extended, my right leg pain increases, and I develop a gait problem in the right leg.

Sitting also helps with my right leg and back symptoms, while lying down with the legs straight can be painful.

The question is, what is my pain generator?

I would opt for some kind of fusion, but it’s hard to do so without knowing for certain if my spondylolisthesis or facets are causing it. I guess I somehow injured both my disc and some bony part of my spine while doing the PT hyperextension with the leg to my side. Perhaps I now have some kind of weird lateral and flexion-extension instability on the L5S1 level along a wide a broad protrusion which irritates different nerves in different positions.

ol99
Participant

March 8, 2021 at 10:27 am

Post count: 14

#33707

Also forgot to add the MRI shows facet hypertrophy at L5S1, the same level as the other pathologies.

Donald Corenman, MD, DC
Moderator

March 9, 2021 at 9:19 am

Post count: 8660

#33712

You note a “6.5mm central-paracentral-foraminal left protrusion on L5S1, with isthmic spondylolisthesis…EMG showed compression on the left S1 nerve, and small radiculopathy on the right S1 and left L5”. “Eventually, 6 months later I started having muscle weakness in the left calf and had an endoscopic discectomy”.

“Now, 3 months later the left leg is much better, but there is almost no change in my right leg…The pain I have originates from the right part of my low back (around the facet probably) and is focused in my right knee. If I try to do back extensions or try to hang from a pull-up bar, the pain increases in intensity and expands to my right foot. I noticed that if I try to walk with my back flexed, all the pain goes away from my right leg”.

You have classic foraminal stenosis due to isthmic spondylolisthesis causing L5 radiculopathy. Since the foramen narrows with standing and enlarges with sitting or flexion, leg pain is worse with walking and improved with sitting or bending forward.

See:
https://neckandback.com/conditions/isthmic-spondylolisthesis-slipping-of-a-vertebra-because-of-fracture/
https://neckandback.com/conditions/foraminal-collapse-lumbar-spine/

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.

ol99
Participant

March 10, 2021 at 12:54 am

Post count: 14

#33715

Thanks for the articles, I gave them a ready and understand a lot more now.

Question: I’ll get a flexion-extension xray today since I’ve never had one. Would there be any value in making a CT?

Because it seems the foraminal/facet pain is mostly in the right side, perhaps I’ve made some kind of tear in the pannus, so not sure how to diagnose that. The MRI (supine) itself doesn’t show foraminal stenosis, so it might be minor.

Also, would an OLIF/ALIF address all of these pathologies, since it seems those procedures don’t remove the facets and other bony stuff?

Donald Corenman, MD, DC
Moderator

March 13, 2021 at 6:22 am

Post count: 8660

#33722

An OLIF, ALIF or TLIF would decompress the nerve root, stabilize the pars fractures and most likely stabilize the segment and significantly reduce the pain. Either an ALIF or OLIF would have to be “backed up” posteriorly with pedicle screws while a TLIF would by definition have pedicle screws placed as part of the procedure.

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.

ol99
Participant

March 13, 2021 at 1:48 pm

Post count: 14

#33727

Yeah, the doctor said that any fusion I would have must have screws because of the pars fracture.

Last question (curious since I always follow the advice from your articles): The disc above my problematic segment looks almost OK. Two radiologist readings (1.5T MRI) didn’t find anything, one (3T MRI) notes bulging and the standing xray says it has discopathy.

I opened the MRI, and could see normal (bright) signal intensity, apart from a darker color in the left sagittal slice. My L5S1 is herniated on the left, so maybe it’s related.

Should I potentially include that L4L5 disc in the fusion? The surgeon said it’s not okay to preventively fuse discs, especially in younger patients. I’m just scared in case that disc is symptomatic and I find that out after surgery…
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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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