Disc reherniation confirmed by MRI... surgeon and pain mgt don't sound hopeful.

Tagged: microdiscectomy, reherniation

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LA_Frankie
Participant

August 29, 2020 at 11:00 am

Post count: 21

#32913

Hello Doctor.

You were very helpful and nice enough to reply to my messages post-op. So thank you. Here is my bleak update.

12 weeks ago I underwent a ‘successful’ (in the words of the surgeon) microdisc and decompression L5/S1. Surgeon removed a large disc that was severely compressing my S1. The compression caused significant atrophy in right leg, calf weakness and I experienced a lot of post-op nerve pain but was doing well after 8 weeks. Going to PT, exercising daily, etc.

Two weeks ago was 10 weeks post-op, in the middle of the night I rolled over in bed and re-herniated the disc! Pain was an immediate 10. Over the past 2 weeks however it has mellowed out and I am able to walk, sit without a lot of pain. I CANNOT do any exercises however without radicular pain returning down the right leg. I am in active rest mode, walking only.

Pain doctor said injections are not as successful on reherniations and he said he was less confident that I would get relief. He suggested I see the surgeon again.

Surgeon wants to take a ‘wait and see’ approach even though the reherniation is at the same location, level and same size as disc he removed. Because the symptoms are not as urgent as before surgery he wants to give it time.

Both doctors give me the feeling that there is nothing they can do for me now. Is this the right approach? I am in pain, just not bed-ridden pain as I was before surgery.

Is it time for a second opinion or is this the standard procedure for reherniation?

Lastly, and most importantly, can a reherniation HEAL on it’s own much like a virgin disc herniation? or does the compromised disc from previous surgery make this a problem forever…?

Thank you so much for your time.
Frankie

Donald Corenman, MD, DC
Moderator

August 30, 2020 at 9:04 pm

Post count: 8660

#32924

You note “12 weeks ago I underwent a ‘successful’… microdisc and decompression L5/S1…10 weeks post-op, in the middle of the night I rolled over in bed and re-herniated the disc…CANNOT do any exercises however without radicular pain”.

Then “Pain doctor said injections are not as successful on reherniations”.

Recurrent herniations are not common at about 15% but do occur and more commonly in the immediate (12 week) post-operative period. They should be treated like first time herniations. Epidurals and PT if there is no motor weakness and withstand-able pain. These can “heal” without further surgery. A redo microdisectomy is required if there is motor weakness or intractable pain. If non-surgical treatment fails in 6 weeks (no improvement greater than 40-50%), a redo microdisectomy is considered.

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.

LA_Frankie
Participant

September 1, 2020 at 8:00 pm

Post count: 21

#32931

Thank you for the prompt reply as always.
My surgeon said exactly the same things you mentioned in your reply.
However, since I still have motor loss in my right calf from S1 decompression 12 weeks ago as well as significant muscle atrophy in right leg, my surgeon said he can do the revision surgery for me sooner than later as to not risk further weakness/atrophy.
He left it up to me to get another ESI. The first one I had this year in May had no effect.

Question: what are the risks involved with multiple ESI within a 6 month time period? Does it negatively effect the outcome of the healing and or structure surrounding the disc herniation?

Lastly, would you advise a patient to try and tolerate the pain for a minimum of 6 weeks after reherniating to reassess surgery as an option?

Regards,

Frankie

Donald Corenman, MD, DC
Moderator

September 1, 2020 at 8:15 pm

Post count: 8660

#32933

The problem with nerve root “healing” is that is is not compatible with normal tissue healing. Tissues heal with inflammation and scar tissue formation which is a big negative for nerve roots. Steroid application reduces healing by reducing inflammation and scar tissue formation. In my opinion, you can have as many as 3 injections in 6 months in your situation (normally 3-4 per year in a normal situation).

Pain is a personal experience and we try to judge how much pain can be tolerated before we pull the trigger on another surgery. It really depends upon how the patient is functioning. With “severe pain”, I’ll repeat a discectomy quickly.

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.

LA_Frankie
Participant

September 2, 2020 at 9:10 am

Post count: 21

#32936

Are ESI following reherniation less effective because of the presence of scar tissue from the previous miscodisc surgery? In my case at 10-12 weeks, would there typically be enough scar tissue to affect the outcome of the ESI?

Same question regarding the revision surgery and recovery? How does the scar tissue affect risks? And will recovery from revision carry any more restrictions than a virgin microdisc?

Thank you kindly!

Donald Corenman, MD, DC
Moderator

September 3, 2020 at 7:28 am

Post count: 8660

#32940

Epidural steroids are generally effective even in the face of scar tissue.

Recovery is not truncated by a revision surgery but the surgery is technically more demanding than the initial surgery.

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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81 reviews

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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Disc reherniation confirmed by MRI… surgeon and pain mgt don’t sound hopeful.