Consider pars surgery for inactive pars? Where to now?

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Antony
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September 9, 2013 at 8:13 pm

Post count: 2

#9349

I am looking for advice regarding back problems that started for me this past February (~7mo ago). I am 28 years old, and have been an athlete my entire life (swimming, running, rugby, cycling). I have also had a pars fracture visible on X-ray for at least 5 years, but had never had any problems with low back pain until now.

This past February, while attending an indoor training session, I thought I pulled my right glute/low back. A few days later, while walking ~1 mile in snow, it blew up into what I thought was hip flexor pain. It has been a circuitous path diagnosing my pain as radiculopathy arising from inflammation around my L5 nerve root… but here are the highlights: 1. Pain increases drastically with walking/standing, best when sitting/lying. 2. Visible pars fracture on Xray, 10% anterolisthesis L5-S1. 3. MRI shows no disc herniation or degenration. 4. Facet joint block had minimal, if any, effect on pain. 5. L5 SNB injection dramatically helps leg pain, but low back & high glute pain remains debilitating. 6. Bone scan shows no hot spots, inactive pars fracture.

Seems like my list of non-surgical treatment options is dwindling. My negative imaging studies & the L5 SNB are encouraging, but it is incredibly frustrating that the low back pain continues. It seems like the only obvious cause is the pars fracture… but the negative bone scan makes that diagnosis not so clear cut. Is it common (or possible) to have a mobile pars fracture that causes low back pain like mine, as well as secondary inflammation of the L5 nerve root, without it showing up on a bone scan? What is a reasonable course of action from here? I have been reading up on direct pars repairs, but with my imaging and pain history it doesn’t seem like there is enough evidence that instability resulting from my pars fracture is causing my pain.

My physio therapist suggested I have a ‘pars block’ cortisone injection to help determine whether the pars is actually the cause of the low back pain. I have also asked my GP whether load-bearing xray can help visualize any mobility/instability in the pars. Is there anything else that I should consider?

Donald Corenman, MD, DC
Moderator

September 10, 2013 at 6:39 pm

Post count: 8660

#9353

You unfortunately have a typical dilemma regarding isthmic spondylolisthesis at the L5-S1 level (the most common level). The pars fractures had occurred most likely between the ages of 8 and 15 years. You ignored this original pain onset as most kids do and your back symptoms became quiescent which is also very common.

Over the years, the disc became degenerative as shear forces were unrestrained due to the pars fractures (the pars act as “doorstops” to prevent shear forces on the disc). Typically, small bone spurs also occur at the site of these pars fractures and you then develop foraminal stenosis at the L5-S1 foramen (see website).

This stenosis may be dynamic (only occurs with motion and stress on the L5-S1 segment and does not show on an MRI which of course is performed in the lying down position). Load bearing X-rays (standing with flexion/extension) can be helpful to understand the instability in this disorder.

Foraminal stenosis causes root compression when upright or walking and especially when bending backwards (extension). The L5 SNRB (root block-see website) gave you diagnostic relief (see pain diary) which is to be expected.

The negative bone scan simply means that these fractures are no longer trying to heal which is very common at your age.

You are not a candidate for direct pars repair if you have a slip of L5 on S1 as this means that the disc is now degenerative. With degenerative changes of the disc, there is no point to repair the pars at this juncture of your disorder.

You can try core strengthening and a neutral spine program along with medications and nerve blocks to treat these symptoms.

If nothing is effective and you are restricted in your activities due to pain, you might have to make the decision to undergo a TLIF fusion down the road (see website). This surgery is only required if you cannot make headway in pain relief.

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.

Antony
Member

September 16, 2013 at 9:41 pm

Post count: 2

#9395

Hello Dr. Corenman,

Thank you for your reply. I have a couple follow-up questions regarding your response:

Re: the disc became degenerative as shear forces were unrestrained due to the pars fractures (the pars act as “doorstops” to prevent shear forces on the disc)….You are not a candidate for direct pars repair if you have a slip of L5 on S1 as this means that the disc is now degenerative.
– My 10% L5-S1 anterolisthesis has been stable since I was about 20. That is, the size of the slip has not changed in that period of time. Is it possible to have a stable, small anterolisthesis at my age without disc degeneration? or is any slip at all, no matter how small or stable indicative of a degenerative disc?

Re: With degenerative changes of the disc, there is no point to repair the pars at this juncture of your disorder.
– Can you explain why this is? Does a direct repair take future treatment options off the table (e.g. fusion?)? Doesn’t stabilizing a pars fracture with direct repair limit the shear forces causing stenosis, disc degeneration, and perhaps extend the life of the disc? Is it possible for mildly degenerative discs to heal once those shear forces are limited?

Why would it be preferable to wait and undergo a fusion down the road rather than a direct repair sooner which may help prevent future disc degeneration?

Thanks again for the advice and information. I really appreciate your taking the time to consider my questions.

Donald Corenman, MD, DC
Moderator

September 23, 2013 at 8:45 am

Post count: 8660

#9453

The 10% slip indicates that the disc has degenerated. I have never seen a slip without a degenerative change to the disc but I assume that this might be possible if you were still very young and the collagen was still stretchable.

Direct pars repairs have two problems in your case, the slip, the time to wait for the repair to occur and your age. The vertebral slip means the disc is already degenerative and the repair is designed to prevent this degeneration. Repairing the pars might prevent further degeneration of the disc but this has never been proven.

The amount of time it would take after a pars repair surgery to be successful is generally about six months. This means six months in a brace restricting your activities to a very low level. This is the same period of time that a fusion of this level takes to mature and the fusion rate is 99%.

This brings up the third point. Successful pars repair rate in the adult population is about 65-75%. Do you want to undergo a procedure that has at least a 25% less success rate, wait the same period of time for repair, and have surgery that is not proven at this time for a preexisting slip? If not successful, you would have to undergo a fusion of that level waiting the same period of time that you did to have the repair.

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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