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  • Seattle Scott
    Member
    Post count: 5

    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
    Post count: 8459

    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

    Seattle Scott
    Member
    Post count: 5

    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
    Post count: 8459

    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

    Seattle Scott
    Member
    Post count: 5

    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
    Post count: 8459

    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

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