Congenital Stenosis with 3 Level Disc Protrusion

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1674Hillcrest
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October 6, 2013 at 8:35 am

Post count: 2

#9538

Dear Dr. Coreman,

I’m a 47 year old male who just got diagnosed with a Congenital Cervical Stenosis and 2-4 mm Disc Protrusions in C3/4, C4/5 and C5/6 and mild to moderate foraminal narrowing on C3/4 and C4/5.
Worst level is C/4/5. Also slight loss of Lordosis, straightening of Cervical Spine

The disc protrusions are causing all kinds of sypmtoms (tingling in my hands, numbness on one foot, weakness in my legs, some muscle twitches)

I went to 3 Neurosurgeons to get an opinion on what the best treament would be in my case and of course I got very different opinions.

Surgeon 1 suggested a posterior approach (laminoplasty)

Surgeon 2 said that Laminoplasty might not yield good results since I have a slight loss of Lordosis and cord might not move back enough.
He suggested a Hybrid of ADR in C3/4, Fusion in C4/5 (also to give me back some lordosis) and another ADR in C5/6.

Surgeon 3 said ADR in patients with Congenital stenosis are not indicated. I asked him why, but didnt get a clear answer. He suggested a 3 Level fusion.

1. Which of the 3 suggestions makes the most sense to you ?

2. Why should an ADR not be performed in patients with congenital stenosis if the ADR removes the obstruction (disc) which causes the spinal compression ?

I also want to leave my options open for later if I need additional surgeries. So my thought was that a laminoplasty is still possible after an ADR but I’m sure not the other way around.

I’m definitely more confused now after I talked to the NS’s and I need to come up with a plan which way to go.

Thank you so much !!

Donald Corenman, MD, DC
Moderator

October 6, 2013 at 8:31 pm

Post count: 8660

#9539

Congenital cervical stenosis means you were born with a spinal canal that is narrowed. This by itself does not generally cause cord compression. However with the typical degenerative changes that all of us undergo with aging-the combination of a small canal with bone spur and disc bulge compresses the cord.

This cord compression is magnified by motion. Bending your head backwards (extension) reduces the diameter of the canal by as much as 30%. Most patients who develop myelopathy (dysfunction of the cord) do so by “battering the cord” with motion. This motion is generally produces painless injury as the cord has no nociceptors (pain signalers/receptors).

The two surgeries designed to decompress from the front are the ACDF and the ADR (artificial disc replacement). The ACDF removes the spurs and bulges and returns the height of the degenerative disc back to “normal”. This procedure indirectly decompresses the back of the canal by this height restoration.

The ligamentum flavum (which lines the back of the spinal canal) buckles into the canal from degenerative changes which obviously narrows the canal even more. The height restoration of the ACDF from the front stretches this ligamentum flavum and reduces the buckling which opens the canal even more.

The ADR on the other hand is not designed to really restore height of the vertebral column (which is why these devices cannot be used on a collapsed disc in the first place). The surgery to place the ADR will remove the bulges and spurs that project into the front of the canal. Of course, motion is preserved by the use of these devices which is good and bad.

The good of course is motion preservation but that comes with a price. These devices can and do fail. If they fail, they are generally easy to revise to an ACDF. Here is the rub. Preserved motion will allow the canal to narrow with extension. If there is too much extension or the body naturally redevelops a spur (motion is the causation of spur formation), this motion can put the cord into compression again.

The laminoplasty is a good tool to use to decompress the canal. This “takes the roof off the house” to prevent the pincer mechanism from compressing the cord. If you do have kyphosis (the reverse of the normal lordosis that most necks have), the surgery is less successful as the cord can still remain draped across the bone spurs in the front of the neck.

The problem with the laminoplasty is that the cord does drift back and a small percentage of patients will have a stretch injury to the C5 nerve (C5 is the shortest nerve and has the least amount of stretch capability). This is generally a temporary setback but there are rare permanent C5 root injuries.

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.

1674Hillcrest
Member

October 6, 2013 at 11:41 pm

Post count: 2

#9541

Dear Dr. Coreman,

thank you so much for getting back to me. No one I talked to has given me such a comprehensive answer yet and is so knowledgable.

So do you think a hybrid solution makes sense in my case, since it removes the anterior obstructions, reduces motion in the worst level but leaves motion in the level below ?

In my MRI report it says that I have a “slight loss of the lordotic curve”. Is this considered to be “Kyposis” and does this exclude me from a laminoplasty ?

I also try to figure which would be the optimal sequence of surgeries in order to keep as many option open as possible in case I need more sugery in the future.
I guess a laminoplasty can always be performed after ACDF or ADR but
can you also do an ACDF or ADR after a laminoplasty ?

Can I submit my MRI and X-Ray images to you to evaluate them and do
a consulation with you ? I could send you a dropbox link.

Thank you so much again for your help !!

Donald Corenman, MD, DC
Moderator

October 7, 2013 at 12:09 am

Post count: 8660

#9542

I cannot predict if a hybrid construction works in your case as every patient has a different need depending upon the specific findings on the imaging.

A “slight loss of the lordotic curve” does not mean anything to me. Is it a kyphosis? Is it a lordosis but less than is expected? Numbers translate to specifically understanding the imaging. For example; “there is a 20 degree kyphosis from c3 to C7 with an angular kyphosis at C5-6 of 8 degrees” paints a picture that anyone can understand.

A “straight” spine can still be a candidate for a laminoplasty. If you have no radiculopathy (nerve root compression causing arm pain), then a laminoplasty will decompress the canal without the need for fusion or ADR.

You can contact the office at (US) 970 476-1100 for information regarding review of your films.

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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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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