Facet Joints

Tagged: chronic neck pain - multiple surgeries

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Donald Corenman, MD, DC
Moderator

August 24, 2017 at 9:02 am

Post count: 8660

#26182

You do have a dilemma if you have continued nerve pain after a successful cervical fusion as well as multiple posterior decompressions (foraminotomies) that were unsuccessful. It seems to be the case if the current CT scan demonstrates solid fusion with continued foraminal stenosis. The big question is what is continuing to cause your pain. Do you have pain due to continued compression of one or more nerves or do you have a chronic pain syndrome where the pain generation is multifactorial and no mechanical source of pain.

If there can be identified a nerve that is chronically compressed (through a diagnostic SNRB-selective nerve root block), then you possibly have a mechanical answer to your pain that can be corrected. The SNRB does not identify why the nerve is causing pain but does identify that the nerve is causing pain. Whether the nerve is chronically injured or compressed is not identified by the SNRB. That is, decompressing the nerve surgically may or may not yield pain relief.

The spinal cord stimulator can be effective to reduce pain but there is no patient I know with a stimulator that describes this device as a miracle. Most will say that they “are better” but not “cured”.

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.

westie California
Participant

August 24, 2017 at 10:53 am

Post count: 138

#26194

Good afternoon Dr Corenman,

CT Scan states:

There is straightening of the cervical lordosis. There is osseous signal intensity noted across disc space. There is good posterior decompression of the spinal canal. The C5-6, C-6-7 and C7-T1 disc space levels demonstrate osseous signal intensity course the disc space consistent with osseous fusion.

There is anterior fusion utilizing anterior plates and vertebral body screws there are bilateral pedicle screws with vertical stabilizing rods from C5-T1.There is wide laminectomies with good posterior decompression of the spinal canal. The neural foramina are patent.

to recap: I have a solid fusion per my CT Scan, my cervical MRI states foramina stenosis, disc bulges effacing epidural compartment and thecal sac, multilevel anterior-posterior spinal postoperative changes, facet joint and uncinate exhibit some sclerosis.

Questions:

1)Should i now focus on the facets or discs in the upper thoracic spine?

2)Request a selective nerve root block of the cervical and upper thoracic spine?

3)Avoid radio frequency ablation of the cervical spine and thoracic? I’m not sure on this one since I have instrumentation to T2. Does this mean the facet shouldn’t move and therefore no pain?

Thanks

Donald Corenman, MD, DC
Moderator

August 25, 2017 at 11:55 am

Post count: 8660

#26204

Your reports are somewhat conflicting as your CT scan notes; “There is wide laminectomies with good posterior decompression of the spinal canal. The neural foramina are patent”. This means that there is no bony compression of the nerve roots (a patent foramen is a wide-open foramen).

This then compares with “my cervical MRI states foramina stenosis”. If you have foraminal stenosis that is not identified on CT scan, either the MRI is over-read (there is no foraminal stenosis but the MRI is mis-read) or there is cartilage and ligament compression present that does not show up on the CT scan (but will be demonstrated on the MRI).

Your pain generators are not yet defined and it will take some work to try and discover what is causing your pain. Solid fusion eliminates the fused segments as a pain generator but the levels below (disc and facet) can cause local pain that radiates into the lower neck, shoulders and scapulae. Selective nerve root blocks (of the already fused levels that demonstrate foraminal stenosis) can indicate pain generation but as I said before, a positive block does not mean the nerve pain can be cured by surgery. You might need facet blocks or even discograms.

If you have instrumentation to T2, I will assume that you are fused to this level and you don’t have motion, therefore pain (disc or facet) from the levels above the T2 level.

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.

westie California
Participant

August 26, 2017 at 8:24 am

Post count: 138

#26208

Good morning Dr Corenman,

I really appreciate your feedback and it has been really a great blessing getting feedback from you. My dilemma has gotten worst. My EMG was performed yesterday and was told by neurologist that I have C3, C4 and C5 nerve compression. A review of my CT Scan images showed foramina narrowing at C3, C4 and C5, she not sure what the radiologist was looking at. Said CT scan was under read and agrees with MRI.

The big dilemma is radiologist findings are different then neurologist, how? second can cartilage and ligament compression cause EMG findings? I called a couple of local imaging centers today and was told they don’t provide 2nd opinion services. I’m exhausted from this back and forth. All I want is relief. Have a great weekend.

Donald Corenman, MD, DC
Moderator

August 27, 2017 at 7:52 am

Post count: 8660

#26211

The EMG is not a great test for nerve compression in the higher nerve roots (C3 and C4) as these have poor connection to the muscles and readings can be too broad. Now, if you have changes in the deltoid muscle (shoulder muscle) that are identified by the EMG, that is some real evidence of problems.

I think you can get another radiologist in the same group as the first one to “overread” these images if you have a conflict between the neurologist and the radiologist. Maybe a new surgeon consultation is now required.

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.

smccrory
Participant

August 29, 2017 at 4:55 pm

Post count: 2

#26237

Hello Dr. Corenman,

Echoing everyone else’s respect and appreciation for your time!

About 2 years ago I had four cervical discs (C3-7) replaced with ProDisc-C Nova units. They surgery and recovery went very well (yay physical therapy and personal training) and I’m able to do just about everything a 50-year old guy should expect including occasional fun with dirt bikes (of course I wear all the gear including a neck brace). Multiple check-up X-rays show that the devices are still perfectly in place and overall I feel way better off than I was pre-surgery. I have no regrets, and have recorded a number of post-surgery journal videos to maybe help others.

Anyway, about a year after surgery I noticed that bending my neck backwards to the left or right caused what feels like (facet?) nerve compression into my shoulder, underarm, lower biceps, forearms, wrists and fingers. I take a prescription NSAID and Ibuprofen daily to reduce swelling and it does seem to help a bit, but I feel like there’s still something structural going on. It seems to make me more prone to repetitive stress in my hands and arms – like they’re always under some nerve flexion. I am imagining that C7-T1 or T1-T2 might be under “stacking” compression particularly on the facet joints or the foraminal canals. Does this sound sensible, or would you think it’s something else?

It hasn’t been bad enough for me to start the whole MRI/CT/XRay and consulting process again, but I should probably set some limits on when to engage neuro or ortho consultation. Any opinions would be most welcome!

Thanks in advance,
Scott in Columbus Ohio
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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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