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  • JeffreyC
    Participant
    Post count: 2

    Hello Dr. Corenman.

    First, thank you for the time you spend responding to questions in this forum.

    My doctor has referred me for a consultation with a surgeon about a possible direct pars screw fixation. I am 37, 5’7″ 160 lbs and have always been active and athletic. I hurt my lower back about a year ago while indoor skydiving. MRI revealed bilateral pars defects at L3 and L4. X-rays in flex/ext show the fractures, but with no spondylolisthesis. Pain was intolerable and increasing with normal activity and exercise, but has recently dropped to low levels after cessation of exercise and by severely limiting driving. Standing and light walking are not a problem for me, but sitting rapidly becomes uncomfortable, and driving even more so. Specifically, what seems to bother me the most about sitting and driving is the pressure in the small of my back. In fact, if I sit with no back support, back pain is minimal (though my back rapidly becomes tired).

    My understanding from reading other posts in this forum is that generally direct pars repair would be less recommended (or not at all) when the disc at that level is compromised. I wanted to know your thoughts on minor issues with discs at non-adjacent levels? The reason I ask is because both of my MRIs noted a small annular tear at L5-S1. If this issue alone should dissuade the procedure, then I would prefer to understand that prior to having CT scans that may incur unnecessary cost and radiation dosage.

    If it is helpful, below are the findings of both of my MRIs:

    Performed May 10, 2016…

    FINDINGS:
    Disc spaces: There is mild disc space narrowing of the L5-S1 disc with mild desiccation.
    Lordosis: Normal.
    Alignment: Normal.
    Vertebral marrow: Normal.
    Vertebral body morphology: Normal.
    Distal spinal cord: Normal.
    Conus medullaris: Ends at the L1-2 level.
    Posterior elements: There appears to be some facet arthropathy mildly at L3-4 and L4-5.
    Spondylolysis: There appears to be unusual spondylolysis with pars defects at L4 and L3 on the right and probably also on the left.
    L1-2: The central canal and neural foramina are not compromised.
    L2-3: The central canal and neural foramina are not compromised.
    L3-4: The central canal and neural foramina are not compromised.
    L4-5: The central canal and neural foramina are not compromised. Mild disc bulge is seen.
    L5-S1:The central canal and neural foramina are not compromised. Mild disc bulge is seen with age-indeterminate small right paracentral annular tear.
    Additional findings: None
    CONCLUSIONS:
    There appear to be unusual pars defects at L4 and L3 bilaterally although there is no spondylolisthesis. There is mild disc bulging at L4-5 and L5-S1 with a right paracentral age indeterminate annular tear at L5-S1. No focal disc herniation or spinal stenosis is seen. The neural foramina do not appear to be compromised.

    Performed June 13, 2017…

    FINDINGS:
    Disc spaces: Mild disc space narrowing seen at L5/S1 with mild desiccation of this disc.
    Alignment: Alignment appears normal with no subluxation or retrolisthesis.
    Vertebral bodies: Appear normal in appearance with no evidence of bone marrow edema or marrow replacement process or compression deformity.
    Conus medullaris: The conus medullaris ends at the L1 level.
    Posterior elements: Mild facet arthropathy is again seen at L3-4 and L4-5.
    Spondylolysis: Spondylosis is again suspected with pars defects at L3 and L4 without spondylolisthesis.
    L1-2: The central canal and neural foramina are not compromised.
    L2-3: The central canal and neural foramina are not compromised.
    L3-4: The central canal and neural foramina are not compromised.
    L4-5: The central canal and neural foramina are not compromised. Mild disc bulge is unchanged.
    L5-S1: The central canal and neural foramina are not compromised. Mild disc bulge is seen. There is a chronic small unchanged right paracentral annular tear.
    Additional findings: None.
    CONCLUSIONS:
    1. There appears to be evidence of mild disc space narrowing at L5-S1 with unchanged pars defects at L3 and L4 consistent with spondylolysis without spondylolisthesis. There is no compression deformity. There is mild facet arthropathy.
    2. Mild disc bulge is seen at L4-5 and L5-S1 with no focal disc herniation. There is no spinal stenosis.

    Thank you again!
    Jeffrey

    Donald Corenman, MD, DC
    Moderator
    Post count: 8656

    Most likely, your pain is generated by the pars fractures at L3 and L4. Your disc degeneration at L5-S1 does not seem to be that bad (“L5-S1:The central canal and neural foramina are not compromised. Mild disc bulge is seen with age-indeterminate small right paracentral annular tear”). This L5-S1 degeneration should not affect any potential for successful pars repair at the L3 and L4 levels and might be an argument for repair sooner than later.

    A good history and physical exam can nail the pain generators down in most cases but if there is any question of pain source, tests can be performed to determine the causes of pain. That would be pars blocks at L3 and L4 and at a separate time (depending upon the results of the pars blocks), a discogram at L5-S1.

    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.
    JeffreyC
    Participant
    Post count: 2

    I appreciate the clarification. Once I have my CT scans complete, I would like to reach out to your office for an opinion. From other posts, I gather that a 64/128 slice CT w/1mm cuts and sagittal/coronal reconstructions is typically necessary to determine whether a direct pars fixation is advisable?

    Thank you again!
    Jeffrey

    Donald Corenman, MD, DC
    Moderator
    Post count: 8656

    You are correct. Please call the 888 number and talk to Lori Fugate. She will help you with this consult.

    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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