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  • sailorone
    Member
    Post count: 5

    I have been told that I need a discestomy for a ruptured disk, but have been told horror stories about the procedure. One thing that I was told is that there is a clinical risk of 10 to 50% that a pars fracture could occur during the surgery and if that happened I would need a fusion and that a fusion had 10% chance that it would effect the disks above and below it. Are these actual statistics or bunk? What are the stats?

    Thank you

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    Your information sources are mistaken. Pars fractures are almost non-existant with a microdiscectomy. In order to create a pars fracture, you would have to thin down the pars with a burr or rongier. The pars is generally not near the laminotomy (bone removed for canal access).

    The need for fusion is normally about 1-10% if there has been a prior herniation and that need is normally many years after the herniation if at all. That means you have between a 90-99% chance of NOT needing a fusion.

    Success rate for surgery for a standard disc hernation causing nerve root compression is 95%. The other 5% have chronic radiculopathy (see website for details).

    Dr. Corenman

    sailorone
    Member
    Post count: 5

    Thank you for your answer. It is great to get a straight answer from a knowledgeable source.
    The info that I am being told does not add up; so from what you are saying, if a pars fracture were to occur during the discectomy, it would be due to a negligent surgeon? Is it possible or very common? If it is possible what are the odds? I am not much of a gambler. Would a surgeon know if he did fracture the pars? Lets say that it did happen and a second surgery was required and a fusion was done; now due to the reduce range of motion, what are the odds of having complications on disks above and below the fusion? Sorry for all the questions, but I am a research engineer and it is a habit.
    Thank you

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    I can say that I don’t remember ever seeing a pars fracture at L5 or L4 from a microdiscectomy but I assume it can happen. The higher levels have a much more narrow pars and I do believe I have seen three or four. That is however out of thousands (or tens of thousands) that I have seen in my office. If there is a foraminotomy however, this does thin down the pars to try and clear the foramen and there is a small percentage that pars fractures can occasionally occur.

    A one level fusion normally does not cause significant stress to the levels around but there is some additional stress. Most of the problems are due to genetics and not the fusion.

    The surgeon might not have noticed the pars fracture as it might not have been present at the time of surgery. This fracture would most likely happen later with the patient undergoing some extension activity and the additional stress causing the fracture.

    Dr. Corenman

    sailorone
    Member
    Post count: 5

    The patient, a close friend was 52 year old male in excellent physical condition and muscular build that exercised regularly and with no genetic dispositions. He had completed a 3 year circumnavigation, on a large sailboat, is a master diver and otherwise a very healthy and active individual before lifting a 25 pound tool back while in a closed confined space that caused the ruptured disk.

    An X-Ray and two MRI before the discecotomy showed no pars fracture and an MRI two weeks after the surgery showed the pars fracture. The patient had not performed any extension activity or stress that would cause the fracture, as his pain post-op prevented and physical activity and physio did not start until 1 month post-op.
    When admitted for the surgery the insurance had authorized and expected to pay for a 2 day hospital stay, but the patient was told to leave the hospital only 2 hours after awaking from the procedure at the orders of the performing surgeon. The patient was in unbearable pain when he was discharged and against his request to stay the night was told that it was not necessary. The patient, then check into a hotel 1 mile from the hospital, with the same pain meds that he had been taking before the surgery. He did not see the surgeon for 2 weeks after the surgery and when he did the doctor said that the nurse had stated that he had got up after the procedure and ran out off the hospital feeling great. The patient replied that he had been run out of the hospital at which time the surgeon replied with anger and defended the actions. It had appeared that the discharge was a setup, to make it appear that the surgery was a success.
    A second surgery with different doctor, fused the L4 L5 with hardware to stabilize and reported that the pars fracture was indeed caused by the previous surgeon. There is no thinning of the pars or any sign of degeneration that would lead to the pars fraction without intervention.
    Two months after the fusion the patient reported bending over to pick up an onion skin off the floor when he felt a pop in the lower back and has sustained constant pain, worse than the pain that lead to the first surgery.
    The pain in his lower back and right leg has been ongoing now for 3 years and his life is un-recognizable.
    So the big question is; if it is it is extremely rare to break a pars during a disectomy, what happened and why did the surgeon attempt to cover his tracks if he had not known of the fracture. Is this indeed a rare event? If so are there any actual statics.
    After witnessing this I am reluctant to have any back surgery what so ever.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    Let us discuss what causes facet or pars fractures. If there was a decompression that thinned the pars or facet down beyond the point of structural integrity, the pars or the facet can be broken, especially with an extension moment. As I noted earlier that I have only seen this 3 or 4 times in the higher levels but today was very different.

    This very day I took care of a patient that had two “minimally invasive” prior decompressions at the L4-5 level at another institution. She was undergoing a TLIF fusion of L4-5 by me. At the level of the prior decompression, she had an L4 inferior facet fracture due to the thinned pars, the first facet fracture that I have seen at this level.

    I would assume that most surgeons measure the width of the pars when doing surgery to determine how “thin” the pars can be made while performing the appropriate surgery. I also assume there are some surgeons who find circumstances that dictate the thinning to the pars to a point that it might be structurally unsound. I do not think the original surgeon knew that the pars was thinned too much and most likely, the fracture did not occur on the operating room table.

    Your friend’s experience was obviously not good. He underwent a microdiscectomy and was discharged from the surgical center in severe pain with no increase in medications from prior to surgery. The question to ask is why his pain was greater than prior to surgery as with a microdiscectomy, normally the pain improves substantially postoperatively. The lack of ability to communicate with the surgeon is something I also cannot explain.

    The second surgeon reports an iatrogenic pars fracture (fracture caused by physician intervention) and fused the segments involved. I assume the fusion was for instability of the segment secondary to the pars fracture.

    Two months after the second surgery, your friend bent down, felt a “pop” and developed pain greater than necessitated the first surgery. He now has had back and right leg pain for three years and his life is substantially changed.

    I would hope he had a new work-up after that episode to determine the origin of the new pain and had it addressed.

    I can understand your reluctance to have back surgery after the experience of your friend but I assure you that his experience is not universal. We have some of the best spine surgeons in the world here in the USA.

    Dr. Corenman

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