Failed Fusion Surgery. Is pseudarthrosis to blame?

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cdebrun2002
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February 14, 2014 at 8:50 am

Post count: 11

#10329

I injured my back on 12/10, which led to intense radiating pain down my left leg/buttocks. I had a laminectomy on 7/11, which did not help. On 2/12 I had a fusion of L5/S1, performed by an Orthopedic surgeon. About a month out of surgery I began to have radiating pain in my right leg/buttocks, along with the original pain in my left leg that was unchanged. On 5/13 I had a fusion on L4/L5, and he redid the fusion on L5/S1. This was done by a Neurosurgeon. Immediately after surgery the radiating pain seemed to be gone, but I had what I would describe as “muscular” pain in my lower back. It was the worst when changing position. As the months wore on the pain remained, but it started to hurt all the time, and the pain changing positions was less. I would still describe it as mostly “muscular” pain, as opposed to the “nerve” pain I suffered before my last surgery. For 9 months my Dr. assured me that this was normal post surgery pain. A couple of weeks ago I talked him into an MRI. It showed “L4-L5 extensive Modic type I endplate change in part related to the presence of a new Schmorl’s node.” He then ordered a follow-up CT. It showed “Postsurgical changes from L4-S1 posterior spinal fusion with evidence of bilateral L4 pedicle hardware loosening and no significant bony bridging across the L4 and L5 posterior elements. These findings are suggestive of pseudoarthrosis.” At my follow-up apt with my Dr. he told me it looked like my pain was just caused by the stress of the surgery, and gave me a NSAID. He didn’t mention the loose screws or pseudoarthrosis. Should I be concerned about the loose screws and pseudoarthrosis, and the fact he didn’t mention them? I have read that pseudoarthrosis is a cause for revision. Do you think that it is called for here?

Donald Corenman, MD, DC
Moderator

February 17, 2014 at 3:37 am

Post count: 8660

#10339

You have undergone a two level posterior lumbar fusion with a pseudoarthrosis (lack of fusion). This will cause lower back pain just as you describe it. I will assume that this neurosurgeon does not understand that your fusion did “not take”.

The good news is that a salvage surgery in your case is not too difficult as the discs of the spine were not touched by the first or second surgery. A TLIF surgery (transforaminal lumbar interbody fusion-see website) will most likely fix most of the discomfort you have and can use the same incision that the first two surgeons used.

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.

cdebrun2002
Member

February 17, 2014 at 9:28 am

Post count: 11

#10346

Thank you for your quick response. Should I be worried that he has missed the fact that “it did not take”? He is my third doctor during this ordeal and overall I have been very happy with him, but it makes me very nervous that when discussing my pain he didn’t bring up the pseudarthrosis.

Is the pseudarthrosis also responsible for the Modic Type I changes that showed up in my MRI? I have become very acquainted with the mechanics of the spine that caused my original “nerve” pain, but I can’t seem to find any info on how the lack of bone fusion on L4 is causing the “muscular” pain I currently have. My Dr says the pain is just a “result of the stress of the surgery”. Could you explain this for me or direct me to a resource that could?

After looking up the TLIF surgery on your website it seems, to my reading, that it is pretty much the same surgery that I had originally (L5/S1). Am I misreading? Since all the hardware is already there and the nerve root doesn’t seem compressed, would he just have to repeat the bone graft part of the surgery? My recovery from the last surgery was about 5 months or so till I felt halfway “normal”. Would the recovery for this be similar or shorter?

I just want to really thank you for providing this service for all of us that have these spine problems. Some doctors do a really poor job of explaining things. Even if they are the best, it’s easy to forget to ask a question in the 15 minutes you see them, which means you have to worry about it for the next month. Providing this resource has, I’m sure, saved the sanity of many people. Thank You!!

Donald Corenman, MD, DC
Moderator

February 17, 2014 at 11:37 am

Post count: 8660

#10349

I do not understand why some physicians do not recognize pseudoarthrosis. Maybe we all want to have the best outcome for our patients and do not want to recognize a failed surgery. Unfortunately, pseudoarthrosis will occur even in the best of hands.

Yes, pseudoarthrosis will cause Modic changes.

Your “muscular pain” is most likely bone pain that “feels” like muscle pain.

I cannot comment on the surgery you underwent without your personal knowledge of what was performed or a reading of the operative report.

All of the hardware might be intact but with a pseudoarthrosis, the screws will most likely be loose and will need to be replaced. Also, BMP (bone morphogenic protein) use is a must in my opinion for a revision surgery.

Good luck.

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.

cdebrun2002
Member

February 17, 2014 at 11:50 am

Post count: 11

#10351

Is the typical recovery from a revision surgery easier than the normal fusion? I have a brace that I wore for a couple of months post surgery, would it help my pain to go back to wearing it?
One last question: I know there are many reasons for a failed fusion, but I had a severe post-op infection, and I have read that antibiotics can interfere with a bone graft. Is that that the case? I know in the long run that the cause is not all that important, but when considering whether to go under the knife again, it would provide a little peace of mind if I knew that the pseudoarthrosis was a “fluke” of the infection.

cdebrun2002
Member

February 17, 2014 at 12:01 pm

Post count: 11

#10352

I’m sorry, I said “one more question” and I was almost right. Will anything have to be done about the damage being done to the vertebral body due to the failed fusion or will it heal on its own once the spine is stable?
I am taking a muscle relaxer, hydrocodone, and a NSAID. Knowing where my pain is originating, is there anything else I could look into taking to reduce pain? Thank you again.
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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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