Continuing L5/S1 pain

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tekoa
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March 6, 2012 at 6:44 am

Post count: 2

#5717

History – lifted improperly in 6/1999, resulting in bulging disc L5/S1. Had three EPI within a year, none were helpful.

Maintained weight and fitness levels to keep me relatively pain free until recently.

Aug ’10 – woke up to experience 8/10 pain. Unable to get out of bed unassisted, sit, or walk. Pain in lower back ONLY.

Between Aug ’10 and now there’ve been three or four episodes of this extreme zapping pain. (Localized to lower back)

Muscle relaxers and pain medication do not relieve it. (apparently the forum software does not like the names of the medications) But they only last two to three weeks. (only!?!) Two of the episodes came on while I was sitting perfectly still – felt like a cattle prod, really.

Had another MRI in Sep ’11 and no real deltas between that and the findings from 2000. Shopped the images to a couple of local (very conservative) surgeons and they said they could not help me.

Have had three facet injections from ~Sep ’11 to Dec ’11. They were quite helpful, and although they only lasted for a week or so each, I felt as if I were on top of the world for the short period that I was completely pain/opiate free.

I had an RFA in January ’12 and it was not at all helpful. I experience a 3/10 pain level at most times, unless I am flat on my back. PT since January ’11. Massage has helped the muscling higher on my back which is tight, apparently compensating for lower back.

My questions:

1) Is there any chance that the facet injections were not conclusively diagnosing the facet joints as my pain generators?

2) If, in fact my facet joints ARE my pain generators, can the RFA be considered as a procedure that could possibly fail?

My PM doctor is not willing to do any more at this point. I am looking for a more permanent fix than, “Maybe you should see a chiropractor or use our DRX9000.”

I am shocked by how quickly my state of mind degenerates when my pain levels increase. I am not overweight, I have done PT for a year, and these ‘episodes’ are still recurring.

Donald Corenman, MD, DC
Moderator

March 6, 2012 at 10:08 pm

Post count: 8660

#5720

Facer injections are diagnostic if pain relief is noted in the first three hours only. This is when the anesthetic is working. If pain relief is noted after this period of time, this relief is a function of the steroid medication. Relief is not diagnostic if noted after this three hour window as steroid may not work locally at the injected facet but spread or become systemic and relieve inflammation at a distant site.

If you had good diagnostic relief (first three hours) and the injection was in the capsule of the facet (directly within the facet), the second confirmatory injection should be a medial branch block. This is the small nerve that gives the facet it’s innervation and there are two for each facet.

If you gain good relief from this second injection, you are a candidate for radio-rfrequency ablation (RFA) which uses a heated needle tip to destroy the small nerve roots that enter the facet. The success rate that I have seen is about 70% for relief of pain.

Why the success rate is not higher is suspected to be anatomic variations of the location of the nerve. The burn zone for the needle is about 3-4 mm. If the nerve is not where it is suppose to be, the burn will miss the nerve and pain will still be transmitted.

Voltaire made the best statement regarding the association of the back and mind. He stated: “The lower back is at the crossroads where the psyche meets the soma”.

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.

tekoa
Member

March 6, 2012 at 11:48 pm

Post count: 2

#5721

Thank you, Dr. Corenman. I suppose my next step is to start over with the diagnostic process. I don’t think insurance will pay for the same tests again. Perhaps taking my medical records with me to another facility is the right answer. I was not unhappy with my current doctor, but if he is not going to keep looking for my pain generator (as I was under the assumption that we all decided it was the facets) then I should probably move on.

I was nervous about the last facet injection because I was not experiencing measurable pain on that day. I always felt more ‘sore’ than better upon leaving the surgical centre.

I wondered if there were standard deviations in the location of the nerve to be burned. I think I offended the PA when I asked about that. I have no idea at this point if I am indeed a candidate for RFA but I was curious if an endoscopic approach offered better success?

A medrol pack was the way that I ended the first, big, ‘episode’ that I had in Aug ’10. Often when I am especially painful, I notice a clunking noise/feeling in the lower back when I rise after sitting.

Donald Corenman, MD, DC
Moderator

March 8, 2012 at 12:34 pm

Post count: 8660

#5732

Clunking noises do not necessarily mean anything as long as the noises are not painful.

If you were not experiencing “measurable pain” prior to your facet blocks, it might be likely that the blocks were not diagnostic. You need to have appreciable pain prior to the blocks and/or be able to perform an activity that typically induces pain after the blocks for the three hour anesthetic window to gain knowledge enough to diagnose the facet as the pain generator.

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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