Direct Pars Repair

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Seattle Scott
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November 13, 2012 at 6:40 am

Post count: 5

#7386

Thank you for your time in responding to posts on this forum. It’s really incredible.

My question is around direct pars repair for a 48 year old male. I used to be a child athlete, was very athletic as an adult, religiously road and mtn biking, skiing 30-40 days a year, playing adult league soccer and baseball. This all changed when I turned 40 and moved out west from the east coast with my family, including children now aged 8, 11 and 13.

I have a batter of tests over the last 10 years: x-ray, flexion x-ray, MRI, ctscan, bone scan, pars block, epidural injections, etc., which indicate a bilateral L5 pars fractures with healthy discs (per MRI taken maybe 18 months ago). I have also seen a number of dr’s, neuros, orthos, chiros, PTs, etc. and all with different opinions. These opinions range from do nothing until you absolutely have to, 360 fusion (with no bmp due to dangers), direct pars repair with bmp, minimally invasvie fusion, try a rhizotomy. The last neuro surgeon I saw in the spring, said my back was fine and it was unlikely the pars defects were the source of my pain. He said I needed to engage in a writing exercise that would 90% cure my pain. It has not.

At this point, I feel pretty lost and not sure how to proceed. I appreciate you cannot give medical advice via an Internet forum, but I was wondering about your opionion on the success of performing a direct repair of the pars on a 48 year old male, no history of smoking and in solid health (including weight) otherwise? If so, would that surgery be performed minially invasively or open?

I really, really want my life back, but it has been difficult to figure out the best options. What are your thoughts on what should I be considering?

Thanks in advance,
Scott

Donald Corenman, MD, DC
Moderator

November 13, 2012 at 6:21 pm

Post count: 8660

#7395

You can look at the pars fracture section in the website as well as the isthmic spondylolisthesis section to gain a better ideas regarding pars fractures and pain generation. The experience of surgeons varies greatly regarding the understanding of these fractures so it is not a shock to find different opinions from different surgeons.

If the diagnosis is unclear, pars blocks (lidocaine injection of the region of the pars), nerve root blocks and a discogram at the level of the fractures can give a much clearer picture of the pain generators. Since the pars fractures most likely occurred between the ages of 8 and 15, it would be unlikely that the disc would be fully intact without a tear 30 years later but stranger things have happened.

A pars repair in my practice in an older population requires a significantly symptomatic patient, an intact, non-painful disc (possibly diagnosed with the use of a discogram) without a significant slip on flexion-extension X-rays, proven pain generation from the pars (positive pars blocks) and no significant bone erosion between the fractured ends of the pars.

Unstable segments, painful discs or significant erosion between the fractured ends of the pars normally requires a fusion. Don’t fret if you need a fusion as there is about a 90% satisfaction rate for fusion in that case.

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.

Seattle Scott
Member

November 19, 2012 at 5:47 am

Post count: 5

#7450

Yes, I reviewed the information on your site, which led me to post on your forum.

I did have a lido infiltration of my pars, which yielded some relief. However, during the procedure you could see that the injection went in 1 side of the pars and then came right out the other side into the surrounding structures. So, according to the dr., he could not be sure the success could be attributed to the pars.

Here is the summary from the MRI about the discs. I guess healthy is relative.

FINDINGS: No evidence of vertebral compression or destructive lesion. No evidence of subluxation. Bilateral L5 pars defects are again noted. Visible caudal spinal cord is normal caliber and signal. Conus terminates in normal location at T12-L1.
T10-T11: Normal disc hydration and stature. No disc bulge, protrusion, or extrusion. No central canal or neural foraminal stenosis.
T11-T12: Normal disc hydration and stature. T12 superior end plate Schmorl’s node, unchanged. No disc bulge, protrusion, or extrusion. No central canal or neural foraminal stenosis.
T12-L1: Normal disc hydration and stature. No disc bulge, protrusion, or extrusion. No central canal or neural foraminal stenosis.
L1-L2: Moderate disc desiccation and moderately diminished disc stature. L1 inferior and L2 superior end plate Schmorl’s nodes, unchanged. Shallow disc bulge causes no central canal or neural foraminal stenosis. No focal protrusion or extrusion.
L2-L3: Mild disc desiccation with normal stature. L2 inferior endplate Schmorl’s node, unchanged. No disc bulge, protrusion or extrusion. No central canal or neural foraminal stenosis. No interval change.
L3-L4: Mild disc desiccation and mildly diminished disc stature. Shallow diffuse disc bulge is unchanged. No central canal or neural foraminal stenosis.
L4-L5: Moderate disc desiccation and moderately diminished disc stature. Focal central protrusion with high intensity zone (annular fissure) indents the ventral thecal sac but causes no central canal stenosis. Mild bilateral facet joint arthrosis causes no neural foraminal stenosis. No interval change appreciated.
L5-S1: Normal disc hydration and stature. No disc bulge, protrusion, or extrusion. No central canal stenosis. Stable mild bilateral facet joint arthrosis but no neural foraminal stenosis.
IMPRESSION:
1. Bilateral L5 pars defects and mild bilateral facet joint arthrosis, unchanged.
2. L4-L5 focal central protrusion with high intensity zone (annular fissure) and mild bilateral facet joint arthrosis without central canal or neural foraminal stenosis, unchanged.
3. L3-L4 shallow diffuse disc bulge without central canal or neural foraminal stenosis, unchanged.
5. L1-L2 shallow disc bulge without central canal or neural foraminal stenosis, unchanged.

I’m not sure if this would make me suitable for a potential pars repair v. a fusion. My concern with fusion, is that while I do have leg pain, it’s not so bad. For me, its more the lack of stability and that I can no longer exercise, ski, bike, run, etc. I would only consider surgery, if there was a good shot of returning to those activities. While I do have pain and some sleep disturbance, it’s not so awful that I cannot tolerate it.

Thanks again for the discussion. I appreciate you cannot give medical advice via the Internet.

Donald Corenman, MD, DC
Moderator

November 20, 2012 at 12:56 am

Post count: 8660

#7457

You do not fully describe your symptoms. Do you have mainly instability type back pain (sharp pain with certain motions like coughing, sneezing and quick back motions), typical chronic low back pain or more leg pain?

The next question is where the pain generation originates? Your L4-5 disc could also cause pain and you don’t want to fix the pars if the disc above is the pain generator. You might be a candidate for a discogram of L4-S1. See the section on the website for this procedure.

I have to tell you that it is unusual for the L5-S1 facets to be degenerative (via the report) with pars fractures present. Pars fractures typically unload the facets and they should normally be pristine. If the radiologist’s report is accurate, you might also need facet blocks to determine if they are pain generators.

I agree with the interventionist in that if the anesthetic “leaked” onto other structures, you cannot be sure if the pars blocks were positive or if there was a false positive test (pain relieved but the targeted structure is not 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.

Seattle Scott
Member

November 21, 2012 at 11:41 am

Post count: 5

#7476

My symptoms are mainly instability back pain. That is, any type of flexion or loading of my back, with movement, will result in sharp pain. Mostly in the lower back, though I do get some leg pain. Then, my back will be painful and stiff for months. For example, if I were to try to go running, the twisting and loading would result in sharp pain pretty quickly. Or, at a minimum, my low back would become really, really stiff. And, then I would set it off into spasms while twisting or sitting later in the day. I am fine to sit and walk, but I really cannot lift more than 20-30 lbs, carry any weight and walk or twist, bike, ski, kick a soccer ball, exercise, garden, etc.

I have had low back pain for 20 plus years. Every few years I would have an event or episode, be in pain for a few days and then it would resolve. Since I turned 40, the instability has become alot worst. I no long can enjoy exercise or activities that I love, such as biking and skiing.

I have never been a big fan of fusion. All of the people I know who have had fusion, were more in pain relief mode. That is, every day and moment of their lives were in pain, and mostly leg pain, and the fusion was aimed to reduce the pain. For me, the everyday pain is not so bad that I cannot tolerate it. What interests me is whether there is way where I can get back to exercising, etc. I’m not sure fusion gets me there, but I have hope for the pars repair.

If you think there is a good shot at improvement, don’t mind making the trip to Vail to see you.

thanks Dr. Corenman!

Donald Corenman, MD, DC
Moderator

November 21, 2012 at 8:47 pm

Post count: 8660

#7479

Instability pain like you note is more likely than not originating from the pars fractures at L5-S1. The L4-5 disc can also cause this pain but less likely. Fusion surgery can be a great way to relieve pain in the back in the properly selected patient. We just completed a study with a 90% satisfaction rate in patients who underwent a one or two level fusion for lower back pain including instability. Pars fracture patients actually tend to do even better with fusion. Nonetheless, you might be a candidate for a repair of the pars.

Please contact my office if you would like to make an appointment. Either call Margaret at 888 888-5310 or call Diana or Sarah at 970 476-1100.

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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