Congenital Cervical Stenosis in combination w. 2 disc protrusions

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Stefan
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December 27, 2013 at 8:27 pm

Post count: 3

#10005

Dear Dr. Corenman,

I was diagnosed with 3 disc protrusions in C4/5 and C5/6 (both 4 mm) and a smaller one in C3/4 (2mm) in combination with a congenital narrow spinal canal (AP 11 mm). In addition to that mild to moderate foramen stenosis.
The first 2 protrusions are already compressing the spinal cord producing mild myelopathic symptoms while C3/4 has just contact to the spinal cord.

I consulted with 2 different Neurosurgeons so far.

a. The first neurosurgeon recommended the removal of the discs in C4/5 and C5/6 and then either a fusion or disc replacement.

b. The second neurosurgeon recommended a laminoplasty instead. He said it widens the entire canal which is important since my entire canal is narrow and by not removing the discs and avoiding fusion for now, I wont have any or less segment degeneration in the levels above and below (at least for now)

What do you think is the better approach here ?

Can you address the foramen stenosis with a laminoplasty as well or do you need a seperate procedure for that ?

Thank you so much for your input !!

Sincerely, Stefan

Donald Corenman, MD, DC
Moderator

December 29, 2013 at 1:51 am

Post count: 8660

#10009

The choice of surgeries depends upon many factors. Laminoplasty will open the spinal canal but has some risks (as any surgery does). The cord will drift backwards as there is more space for the cord. This cord drift will stretch the nerve roots (as they are obviously attached to the cord) and can trigger a C5 nerve irritation. Most of the time, this irritation fades away but not all the time.

In addition, any nerve root compression originating from the anterior side will not be removed. This condition is called uncovertebral joint hypertrophy-the most common cause of cervical nerve compression (see cervical radiculopathy on the website). The posterior approach can open the nerve hole (foraminotomy-see website) but this can be ineffective to decompress the nerve as this spur projects from the anterior side.

The anterior approach-either an ACDF (fusion) or an ADR (artificial disc), can decompress the cord and any nerve root that is also compressed by the uncovertebral joint spur or a herniation.

Generally, with stenosis that compresses the cord and causes myelopathy, I tend to recommend an ACDF. The canal is already very narrowed and an artificial disc allows motion. This motion can again produce spur formation and a recompression of the cord.

There are circumstances that an artificial disc can be used in spinal cord compression and myelopathy. If the canal is large enough but the herniation is also large, then removal of the herniation will open up the canal and an artificial disc will not place the cord in jeopardy again as the disc will have been removed.

Now-if the entire canal is significantly narrowed and the entire cord could be in jeopardy, the laminoplasty could be indicated. There are even times that both a laminoplasty and an ADCF are required. As you can see, every situation requires a specific plan.

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.

Stefan
Member

December 29, 2013 at 3:38 am

Post count: 3

#10011

Dear Dr. Corenman,

thanks a lot for your detailed response !!!!

There were two things you mentioned I did not quite understand:

You said: The posterior approach can open the nerve hole but this can be ineffective to decompress the nerve as this spur projects from the anterior side.

1. Does this mean that in general the bone spurs are always projecting from the anterior side or does it mean that laminoplasty is ineffective IF the
bone spurs project from the anterior side ?
How do I know if foraminal stenosis is anterior or posterior ?

2. If the foraminal stenosis can be addressed with a laminoplasty, wouldn’t that be the procedure to go with, since you avoid fusion and also adjescent segment degeneration ?

My biggest concern with the fusion is that I will need surgery again and again since the discs above and below have to endure more stress which I
thought could be avoided with a laminoplasty since there is no fusion.
Is my thought process flawed ?

Thank you again !!

Sincerely,

Stefan

Donald Corenman, MD, DC
Moderator

December 29, 2013 at 8:22 am

Post count: 8660

#10012

You need to understand that there are two separate structures that can potentially be decompressed; the spinal cord and the nerve root (or roots). A laminoplasty will decompress the spinal cord but not the nerve root. A foraminotomy will partially decompress the nerve root by opening up the volume of the nerve hole.

If however the root is compressed by an anterior bone spur (originating off the uncovertebral joint), the foraminotomy will not remove this spur and the nerve can still be tented over the spur in spite of the posterior foraminotomy.

Adjacent segment degeneration is not changed by artificial disc replacements. It possibly may be changed by a laminoplasty but with a posterior foraminotomy, this removes about half of the facet witch can lead to instability or neck pain.

It is uncommon to have adjacent segment breakdown after any of these procedures but it can happen so pick the procedure that gives the best “cure” rate with the best success rate.

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.

Stefan
Member

January 1, 2014 at 12:04 am

Post count: 3

#10021

Dear Dr. Corenman,

thanks a lot for clarifying.

I’m trying to make a decision which way to go.

Since I dont have any radicular sypmtoms, wouldnt it be better to choose the posterior approach since it also addresses my congenital narrow canal ?
I’m just worried that if I get 2 fusions, which only address the disc
protrusions, I might end up again with myelopathy due to adjescent segment degeneration once the next disc will start to compress the spinal cord which then would require surgery again.
By doing a laminoplasty the whole canal is getting bigger and a 3mm disc protrusion most likely wont cause any symptoms and also wouldnt
cause adjescent level degeneration to that extent.
Is my thought process somewhere flawed ?

Thank you so much and a Happy new Year !!

Donald Corenman, MD, DC
Moderator

January 3, 2014 at 3:30 am

Post count: 8660

#10027

The fact that you have no radicular symptoms is very helpful as you do not need to consider nerve root decompression. If you have minimal neck pain, then the laminoplasty is the better way to go. This will decompress the entire canal with only a small chance of radicular involvement.

The chance of segmental degeneration is limited and this procedure does not preclude an ACDF in the future if necessary.

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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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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