Direct Pars Repair L5 w/ Spina Bifida Occulta

Tagged: Pars repair

Viewing 6 posts - 1 through 6 (of 6 total)

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Whotediasy
Participant

October 29, 2016 at 9:10 pm

Post count: 4

#23311

Hello,

I have a bilateral pars defect/fracture with a minimal slip of the L5 on S1. A doctor said that my pars defect appears to be congenital on the left and fractured (about 8-10 months ago) on the right. My disc is intact. Recent X-rays found that I also have a mild case of Spina Bifida Occulta at L5. The bones of my vertebrae appear to rap around and overlap parallel to each other rather than unite. I’m only 38, healthy, and active. I’m really hoping I could have a Direct Pars Repair surgery rather than a fusion.

Does the Spina Bifida Occulta automatically disqualify me from all methods of a Direct Pars Repair? Are there certain methods that might work better than others with my condition?

About how long would a woman have to wait to get pregnant after a Direct Pars Repair surgery? My husband and I are weighing conceiving a child now vs having surgery now. I am concerned that another pregnancy could cause my L5 to slip further and prevent me from being a candidate for a Direct Pars Repair.

A local orthopedic prescribed a rigid back brace but said he doubts it will work since the fracture is old. I am researching options in prolotherapy, PRP, and stem cells (injected into the pars fracture) but I’m wondering if that will all be a waste of time and money with no results at the end.

I’d really appreciate receiving your opinion and can forward my MRI and X-rays to you if you think you may be able to help me. Thanks!

Donald Corenman, MD, DC
Moderator

October 30, 2016 at 10:16 am

Post count: 8660

#23313

There are many factors that make a pars repair possible or not recommended. These include the amount of slip, the amount of atrophy of the pars (hypertrophic vs attenuated), the amount of gap, the stability of the vertebra and your age. The spinal bifida occulta also reduces the success rate of repair as there is one more point that can allow motion to the repair.

All of the other treatments you mention (“prolotherapy, PRP, and stem cells”) are a waste of time for this disorder.

You need a CT scan of the pars fractures to determine if repair can be feasible.

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.

Whotediasy
Participant

November 4, 2016 at 7:25 am

Post count: 4

#23357

Dear Dr Corenman,
Thank you so much for your reply. I have an Abdominal/Pelvic CT scan from July. Would that do?

What is your opinion of the various methods of direct pars repair surgery: pedicle screw w/universal hook system, direct pars screw fixation, etc?

How long would a woman have to wait to conceive after a Direct Pars Repair surgery?

Is prolotherapy/prp a waste of time for lax ligaments in the sacrum / SI joint dysfunction?

Donald Corenman, MD, DC
Moderator

November 4, 2016 at 11:12 am

Post count: 8660

#23359

Abdominal/Pelvic CT scans are generally not accurate enough to carefully look at the pars defect to determine the pars status (atrophy, hypertrophy, distraction, attenuation). A devoted lumbar CT scan on a 64 slice scanner (128 is even better) with one millimeter cuts and sagittal/coronal reconstructions is recommended to determine the anatomy of the defect. You don’t have to have the entire lumbar spine imaged-just the L5-S1 level. You also need standing X-rays of the lumbar spine with flexion/extension views to understand the stability of the L5-S1 level.

I like the direct repair with screws directly through the defect as this screw acts as “rebar” in concrete and is much less obstructive to surface area. The pedicle screw construct is just fine (and easier to perform) but has less success rate in my opinion.

Pars defect repairs take at least 6 months to heal and rarely can take up to one year. Pregnancy during this period of time is contraindicated as the mechanics of the spine change dramatically and the hormone relaxin is secreted during pregnancy which allows ligament stretch.

PRP and prolotherapy are just fine for sacroiliac disorders (as long as there is no tear in the anterior capsule of the SI joint in the case of prolotherapy).

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.

Whotediasy
Participant

November 9, 2016 at 7:38 am

Post count: 4

#23392

Dear Dr Corenman,

Thanks again for your reply. Is the direct repair with screws that you do similar to the Bucks repair? Do you use a bone graft or BMP?

I know you advised I need a lumbar CT scan to determine if a direct pars repair if feasible. But would you possibly be able to tell if a direct pars repair was NOT feasible just by looking at my lumbar MRI, A/P CT scan, and x-rays?

I hate to go and get more radiation exposure if its at all possible to tell from the imaging I already have. As I said, my husband and I are still hoping to get pregnant again in the future. If my only option at this point is a fusion, I’ve been advised it may be better to get pregnant first and then get a fusion because I am 38 and running out of time. My concerns with that plan though are if pregnancy would make the slip worse, worsen the pain, possibly being on bed rest for months, and if my L5 slip could cause problems with a vaginal delivery (delivered my first 2 vaginally easily.…but that may have been before I had a slip).

Do pars fractures bleed? My lumbar MRI reads that there is fluid surrounding my right pars fracture. My A/P CT scan back in july also read that there was “soft tissue fullness between the terminal ileum, cecum, and psoas muscle” which is what they believed was causing my right sided pain. Could that be possibly related to the fluid around the pars fracture? Also, could pain from a pars fracture radiate down into the butt? I have had chronic pain on the right side about an inch below my SI joint and just to the right of my sacrum.

Thank you again so much for all the time you give reading and answering questions.

Donald Corenman, MD, DC
Moderator

November 12, 2016 at 1:45 pm

Post count: 8660

#23413

The bucks repair is similar to my procedure as well as many individuals who repair pars defects. I always use bone graft and BMP as it is difficult to get these ends to unite and both graft materials do help to advance repair.

“Would you possibly be able to tell if a direct pars repair was NOT feasible just by looking at my lumbar MRI, A/P CT scan, and x-rays”? Do you have a previous CT scan as implied in your question? If you do not, a CT scan is imperative to understand the defect and if a repair is possible. The scan can be collimated (blocked off) to only expose the L5-S1 region and shield all the other areas to reduce X-ray exposure.

If you do get pregnant, you do have a chance of advancing the slip. Nonetheless, if you need a fusion now, get pregnant, deliver and the slip increases 5mm, it will not make the fusion surgery any harder to perform. If however your slip is minimal, you have good opposition of your pars fracture ends and are thinking of a repair, then any additional slip will make pars repair not possible.

Normally, once fractured and the inflammatory period has passed (3-6 months), pars fracture won’t bleed. That is unless you lift or traumatize the area by tearing the scar formed between the fracture fragments as scar will bleed. Normally, the fluid found around the pars is a seroma and from chronic irritation to the pars. This fluid can indicate an atrophic pars (a pars that has thinned down and is more difficult to fix).

SI joint pain (“chronic pain on the right side about an inch below my SI joint and just to the right of my sacrum”) is a very common referral site for pars fractures.

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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