[Renee123]

#22454

Im not disagreeing with you, just letting you know what I’m hearing.

I believe the reason why surgeons warn about muscle stripping is because they make 4-8 inch incision in back. They say the need to get long enough to get wide enough. Whereas you have a two inch incision and use microscope.

Perhaps there is less recovery with your incision.

I would love to meet you someday. A lot of this is just common sense and I seem to follow your logic. I may have to fly all the way to Vail !

[Donald Corenman, MD, DC]

#22459

I am sure that there are still dinosaurs who continue to use large central incisions to allow fusion surgery to occur but I can tell you this number diminishes on a yearly basis. To perform my technique. the surgeon needs an O-Arm and a microscope (but I would assume the “minimally invasive surgeons” use a similar technique).

I welcome individuals who disagree with me as the argument sheds light on subjects and both individuals should learn something from the disagreement.

The recovery from my incision is about exactly the same as the minimally invasive surgeons but the ultimate results are better in my opinion.

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.

[Renee123]

#22460

So I assume a long mid line incision through the back could generate residual pain and muscle stripping?

I have consulted with some top surgeons. None of them use microscope or O arm for open TLIF. They do an open incision and place pedicle screws with microscope glasses. Most do not use boomerang cage, some are moving to tri-tanium cage or expandable cages.

They all have a 4-8inch incision and is the reason for MIS TLIF.

In addition when it comes to BMP most surgeons are not well versed on where it goes and why. I had a surgeon tell me he would do a PLIF with two cadevor bones inserted in place of cage and put BMP in the middle and not on the sides. Does that sound right to you ?

Most surgeons do not communicate the way you do. They say one thing and then flip flop. They do not like to be questioned and when they are they always have a different way to do the surgery. Unlike yourself, where you have one set way and you do not deviate from what works for you.

You have a real passion for helping people. I appreciate your help.

[Donald Corenman, MD, DC]

#22461

Long incisions are not as bad as the “minimally invasive surgeons” would like to advertise. I think a study of success rate of the old standard longer incisions and MIS incisions at 6 months would yield comparable results.

I am surprised that most surgeons in your area don’t use microscopes. Using loops (magnifying eye glasses) is an old respected technique but lighting is not as good and the assistant cannot see the view that the surgeon sees.

The boomerang cage it not essential. I like it because the surface area for bone graft is large and I feel allows a higher success rate but I cannot state this as a rule as I have not yet studied this.

BMP can be temperamental and needs to be sequestered (kept away from nerve roots). This can be done multiple ways but the technique you mention would somewhat concern me.

Surgeon communication is generally quite poor. I would love to improve that part of the surgeons skills (which is the purpose of this website).

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.

[Renee123]

#22462

“The pain is not generated from the muscle but from stretching the collapsed annulus that is typical with all fusions for degenerative discs. If the disc height is not restored, there is less pain but less restored alignment.”

What did you mean by this ?

Also, what is osteolysis ?

Your argument for boomerang over expandable cage again makes logical sense. If the whole point of the TLIF is to fuse then why on earth would I want to use a smaller cage ? Do you happen to know the size of the bommerang cage ?

My surgeon tells me that the industry is moving away from peek cages and using tri-titanium for TLIF.

[Donald Corenman, MD, DC]

#22463

With degenerative disc disease, the height of the disc collapses when the nucleus drys up and the annulus tears. Typical disc height in the situation of IDR (isolated disc resorption) goes from a normal of 10-12 mm to a height of 0-1 mm.

To perform a TLIF, the disc height needs to be restored to the maximum height that the degenerative annulus will allow. This restores sagittal (side-view) alignment and opens the foramen to allow decompression of the nerve root. This requires considerable work to free up any intradiscal adhesions (quite common) and stretch the disc space back to the maximum allowable height. The height normally can be restored to about 6=8 mm (the typical size of the cage that can be placed). This significantly stretches out the old, contracted fibers and this is what causes the most pain in the immediate post-operative period.

This is why I like to inject duramorph (intrathecal or “in the nerve sack” morphine) which controls pain for 24 hours. Once this period passes, pain is no more than any other spine surgery.

Osteolysis is the absorption of the calcium out of bone. This appears as a “hole” in bone. It can be caused by the use of BMP and is not uncommon. The reason is that BMP activates stem cells. Some turn into osteoblasts which create bone and some probably turn into osteoclasts which absorb bone. How and why osteoclasts are activated is still unknown but some principles seem to be common. Exposed cancellous bone under the influence of BMP (as occurs with endplate fractures which is why I don’t like expandable cages) seems to create osteolysis.

Now this does not mean that osteolysis has to be a real problem. Early in my use of BMP, I found more osteolysis than currently I note. In each case, the osteolysis eventually “filled in” with bone but this meant that there would be an extra three months to fully heal. I can assume the some cases of osteolysis could be problematic but I have not seen these cases (yet).

I know the boomerang cage is approximately 10×30 mm.

The use of titanium cages makes no sense to me as they are radioopaque (can’t see through them with X-ray). Also, titanium can distort MRI images. This makes titanium a less appropriate choice to use as a spacer. PEEK cages however cannot be used as a mechanical distractor. I assume that this surgeon uses an expandable cage and this would require metal for the distraction mechanism. You cannot make an expandable cage without metal. This is why this surgeon states “the industry is moving away from peek cages and using tai-titanium for TLIF”. I would disagree.

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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