Discectomy or Spine Fixation/Fusion (with screws and rods)?

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rangdalp
Member

June 18, 2014 at 2:18 pm

Post count: 3

#11051

Hello Doctor Corenman,

I am from India….and I need a second opinion on my situation.

I’ve had a micro-endo-discectomy for L4-L5 disc prolapse, back in 2009. I’am again in the same situation now and while my previous neruo surgeon is suggesting another micro-endo-discectomy, whereas the spine surgeons are advocating for spine fixation of S1, L5 and L4 with screws and rods.

Please suggest what is advisable and beneficial in my case.

Below are my details:

Name: Pradeep Rangdal
Age: 44 years
Gender: Male
Weight: 72.5 Kgs

Previous History of lower back ailments:

Year 2005:
•Had a sudden catch in the abdomen (while bending forward)
• Took complete bed rest for 1 week and was able to get back to work
• Since then had lower back pains, on and off

Year 2009 (March): This happened in the U.S (Maine state) while I was on a short business trip…
•Started getting sever pain in the lower back (mostly left side) and entire left leg
• By the time I came to India my left leg was completely numb
• MRI showed:
◦ Disc Prolapse at L4/L5 with caudal migration and compressing L5 nerve root on left side
◦ Grade-1 anterior listhesis of L5 over S1
• Doctor (Neuro Surgeon) suggested and performed micro endo discectomy (minimally invasive) to remove the protruded disc fragment and pain in the left leg was completely gone.
• There was no treatment provided for anterior listhesis of L5 over S1
• Took rest for 2 weeks and was able to get back to work
• Lower back pains still persisted, on and off

Year 2014 (March 17th – till date):
•Spasm and sever pain in the lower back with limited mobility (was not able to walk around, bend or sit)
• Took complete bed rest for 1 week and felt much better and started going back to work
• After 1 week, started feeling radiated pain from left hip/butt region to the entire left leg
• MRI shows the following:
– Diffuse disc bulge at L3-L4 level causing mild thecal sac indentation
– Posterior left paracentral disc extrusion at L4-L5 level with caudal migration causing compression over the traversing eft L5 nerve root with midl impingement over the thecal sac
-Bilateral spondylolysis at L5-S1 level with grade 1 spoldylolisthesis
-Left facetal arthrosis at L4-L5 level
-Post contrast study shows enhancement of the disc material at L4-L5 level
-Enhancement also noted at the left facet joint
-Vertebral bodies are normal in height and signal intensity pattern
-Pedicles, laminae and spinuous processes are normal
– Visualized spinal cord and conus medullaris are normal
-Both psoas muscles are normal
-Both sacro-iliac joints are normal

F18 Bone Scan shows:
-Scan findings suggestive of left L4/L5 and right L5/S1 gacent joint arthritis.

• Current Symptoms:
◦ Continuous radiating pain from left hip/butt region to the entire left leg
◦ Pain in the lower back (mostly on the left side)
◦ Less pain while walking and more pain while sleeping, sitting and turning/bending on the left side
◦ Have to take support while sitting and getting up from the chair
◦ While in sleeping posture, feels pain when sleeping on the left side
◦ While in sleeping posture, feels pain when turning to the left and right side (need to put extra effort)
◦ Cannot walk more than half a mile
◦ Cannot sit for more than 30 minutes (can feel constant pain in the left leg and lower back even while sitting for those 30 minutes)
◦ Tingling sensation in the left leg (after I get up from bed) which goes away after 5 – 10 minutes of walking
◦ Left leg is weaker than the right – Need to use the right leg first while getting out of the bed or chair

Thanks,

Pradeep Rangdal

Donald Corenman, MD, DC
Moderator

June 18, 2014 at 10:38 pm

Post count: 8660

#11059

You have two separate diagnoses; isthmic spondylolisthesis at L5-S1 and a recurrent disc herniation at L4-5 left side. Boiling down your symptoms, it sounds like the majority of your symptoms are left leg pain with weakness and some lower back pain.

Were you were able to live with your lower back pain prior to this new disc herniation? If so, the leg pain due to your herniation is your impairing symptom.

If this is the case, I would consider only a repeat microdiscectomy and not a fusion. If however, your lower back pain prior to this new herniation was disabling, then the fusion might be the better way to go.

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.

rangdalp
Member

June 18, 2014 at 11:24 pm

Post count: 3

#11061

Thank you, so much for your response, Dr. Corenman!!

Yes, I do understand that micro discectomy will cure my left leg pain. But, due to continuous disc herniation/degeneration, won’t L4/L5 become susceptible to extra pressure and may lead to spine destabilization (in specific region)and may be another round of surgery in the near future? Other than L4/L5, discs at L5/S1 and L3/L4 are not looking healthy too. Per the Neuro Surgeon there may be chances of a relapse of the disc herniation again, post the discectomy.

Also, to answer your question, yes before this NEW disc herniation, I was able to carry on with lower back pains (on and off) but, my life style was limited….I couldn’t sit for long hours, can’t stand for long hours and also can’t walk enough.

Ex:
1.If I am walking in a mall then I would get a back pain after I walk around for 1 hr.
2. I would get a back pain after driving my car (for more than 1 hr) in city roads. FYi – Indian cities have lots of traffic congestion and most of the India Cars have manual gears with clutch which we need to use with our left leg a lot. Since my left leg is weak (may be due to my first discectomy), using the clutch exerts lot of stress.

I’am 44 yrs old. Is it too early to go for Spine Fixation/Fusion? If I do opt for it, will there be any changes to biomechanics of my spine/lower back and my lifestyle and how will I be doing in the long run (10-20 years down the lane)…These are some of the questions I am looking out for answers.

Again, thank you so much for your valuable opinions.

Pradeep Rangdal

Donald Corenman, MD, DC
Moderator

June 19, 2014 at 9:56 am

Post count: 8660

#11066

Fusion will most likely help your lower back pain. There is not enough information to let me determine what levels should be included in the fusion.

If you can live with your previous back pain, then the microdiscectomy is a good idea. Yes, you have a 10% chance of a recurrent herniation but those are not bad odds to me. The L4-5 level might actually stabilize over time if degeneration stiffens this segment.

The microdiscectomy does not preclude you from having a fusion in the future.

The decison should be made taking into consideration the back pain and how impairing it is.

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.

rangdalp
Member

June 20, 2014 at 8:46 pm

Post count: 3

#11073

Thank you again, Dr. Corenman.

Pradeep
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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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