Considering Second ADR

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jake90810
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March 28, 2013 at 1:01 am

Post count: 2

#8287

Dr. Corenman,

Thank you for reading this post and taking the time to give me your opinion. This site is such valuable source of information!!!

My history:

No history with chronic neck pain until weightlifting accident Sept 2004. Resulted in large disc protrusion at c6-7. After 6 months of conservative treatment had ADR surgery with a PCM disc at c6-7. ALL symptoms and pain were completely relieved. Back to work in 1 week. Resumed physical activities – weightlifting, roller hockey, skiing.

Pain and symptom free until recently, appx Nov 2012. Current symptoms may have been brought about by a roller hockey incident where I fell head first into the boards. I did not wake up the next day and notice immediate neck and radiating arm pain, but that may have been the trigger.

Current symptoms since early December 2012:

Pain in neck, down into shoulder blade area, right and left side. Sharp stabing pain shoulderblade area. Pins/needle/ach in the right and left outer upper arm area, near sholder. Pins/needles/ach right outer forearm down into right thumb. Recently, developing same feeling in left thumb as well. Symptoms worse when sitting, coughing, sneezing. I can take the pain, but not the pins/needles/ach in the arms.

Treatment: Physical therapy/ chiropractor treatments. Medications (motrin, vicoden, Celebrex, medrol pack). EI shot at the C5-6 and C4-5 levels (relief lasted one day, then returned)

My Question:

The symptoms point to the C5-6 level as the source. Considering how well I responded to a prior ADR, with similar symptoms, I am leaning towards ADR surgery.

Also, do you see anything in the MRI report that would be consistent with tingling feelings in both feet and sometimes thighs?

Any observations, comments or suggestions are greatly greatly appreciated.

MRI Date: 02/07/2013
C2-3 All normal
C3-4
Mild loss of disc height is present. 1 mm diffuse disk bulge is eccentric towards the right and mildly effaces the thecal sac. Cord not compromised. Right neural foramen is normal. New mild left neural foraminal stenosis is present due to uncovertebral hypertrophy.

C4-5
Moderate to severe loss of disc height and endplate osteophyte formation is asymmetric towards the right has increased. Diffuse disc bulge is associated with increased size of 2 mm focal right paracentral disc – osteophyte complex which results in increased mild central spinal stenosis and flattening of the right ventral aspect of the cord. Mild bilateral neural forminal stenosis due to uncovertebral hypertrophy is unchanged

C5-6
Moderate to severe loss of disk height, the irregularity of the endplates and osteophyte formation towards the right I unchanged. Diffuse disc bulge is associated with a 2-3 mm focal left paracentral protrusion resulting in mild to moderate central spinal stenosis and flattening of the cord is unchanged. Severe right neural foraminal stenosis is increased and severe left neural foraminal stenosis is unchanged.

C6-7
Artificial disc placement which results in geometric distortion at this level. No compromise of central canal or cord is present. Neural foramina are normal

C7-T1
Disk, central spinal canal and neural foramina are normal.

T1-T2
Moderate loss of disc height associated with irregularity of end plates and osteophyte formation. 5-6 mm hemangioma within T1 vertebral body. Central canal and neural foramina are normal

T2-T3 All normal

Donald Corenman, MD, DC
Moderator

March 30, 2013 at 4:55 am

Post count: 8660

#8306

An ADR might work at the C5-6 level but there are some considerations that need to be taken into account. First is that this C5-6 level is very degenerative based upon MRI findings with “moderate to severe loss of disc height”. Reconstructing the C5-6 level to the previous height of the disc (which is what the ADR does for the most part) can increase or create new neck pain.

The second is that the ADR is designed to reduce the stress on the levels above and below to reduce degenerative changes. This device at C6-7 unfortunately did not work for you as C5-6 became very degenerative in spite of this ADR.

If you have developed myelopathy from compression of the cord, this disorder could be the source of of the tingling feeling in your legs. A simple physical examination can reveal if this is the case.

You might be better off with an ACDF but without review of your MRI and X-rays including flexion/extension, this is an unknown.

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.

jake90810
Member

April 3, 2013 at 5:43 am

Post count: 2

#8335

Thank you Dr. Corenman for your response.

Regarding the ADR at c6/7 in 2005, yes it is an unknown whether it simply delayed the inevitable or not. At that time, I consulted with several top doctors in LA. Two recommended a 2-level fusion, one recommended a 1-level and a fourth said 1 or 2 level. Ultimately I opted to participate in a clinical study for a 1-level ADR.

Regarding your comment “Reconstructing the c5-6 level to the previous height of the disc (which is what the ADR does for the most part) can increase or create new neck pain.” Would a fusion not also do the same since a graft is placed between the vertebrae? Or is the graft not as “thick” as an ADR? What would be the cause of the new pain and why? Is there a term or description for this I can research?

Also, regarding the level causing my symptoms. The pins/needles/ach raiding down the outer forearm into thumb area indicates c5-6. But would c5-6 also cause the same type feeling in the left and right outer (lateral) middle arm area (I said upper previously by mistake). Occasionally, this feeling seems to be more along the bicep area (middle part) of my arm and sometime it feels closer to the triceps area (back) of my arm. The MRI indicates severe right and left foraminal stenosis at c5-6. The c4-5 level indicates “mild” only. Lastly, is foraminal stenosis caused by the “severe loss of disc height” at c5-6?

Once again thank you very much!!!

Donald Corenman, MD, DC
Moderator

April 3, 2013 at 8:27 pm

Post count: 8660

#8338

An ADR (artificial disc replacement) restores at least some of the lost height of the degenerative disc and that can be a problem. The long-standing collapse of the disc height produces contraction of the capsules and wear of the facets in the back of the spine. Distracting these facets (which might have worn down over the ensuing years) and reintroducing full motion can create new onset facet pain. Also, the contraction of the facet capsules might not allow much motion of the new ADR. See anatomy of the cervical spine on the website to understand this.

Yes, the graft used in fusion is about the same height (or sometimes even thicker) as the ADR but the graft fuses the two vertebra together so the motion stops. Without motion, any potential degenerative facet pain is eliminated (pain only occurs with motion).

The symptoms you note are consistent with a C6 nerve involvement (C5-6 foraminal stenosis).

Yes, the severe foraminal stenosis is caused by the loss of disc height at C5-6. The uncovertebral joint which is the inside wall of the nerve root foramen develops a mushroom-like bone spur and the combination of this spur and the loss of disc height finally crowds out the nerve.

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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