Gait disturbance post disc herniation

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lumipop
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April 13, 2014 at 1:55 pm

Post count: 1

#10711

Hello Dr Corenman, you have an excellent site and I just happened to come across by searching for my condition.
Kindly, I’d like to ask your opinion about my situation: I had for couple of year a right L4L5 herniation which was manageable with physiotherapy and no nerve symptoms lately (had a bad episode of L4 pain back in 2011, but got better with physiotherapy).
In Oct. 2013 while doing housework/gardening (after a period of very inactive and working a lot in sitting position) I felt like a thread going from my lumber area into my left heel. Shortly after that I could not keep my left hip up and developed some sort of foot drop (could lift the foot with big toe, but no heel walking. The pain down the side of left lower leg was excruciated for 6 weeks, then got better. Now at 6 months I still get some tension in the side of lower left leg and foot drop started to improve (but still cannot do heel walking for long and I cannot do it with shoes, only barefoot). The biggest problem is that my gait is not normal, I cannot keep my left hip up(although improved from where I was, still I am limping on the left).
Here are my MRIs :
Dec. 15 at 6 weeks – pain was better on the left side:
L4 L5- diffuse disc bulge with superimposed broad based right paracentral and intraforaminal protrusion, mild to moderate central stenosis, mild left neuroforaminal stenosis and moderate right neuroforaminal stenosis with contact on exiting right L4 nerve root. Slight compression on both descending L5 nerve root and true lateral recess, more on the right.
L5 S1 –diffuse disc bulge asymmetric to the left with moderate left neuroforaminal stenosis and mild right neuroforaminal stenosis with contact on both exiting L5 nerve root more pronounced on the left.
Feb. 26 @ 3 months:
At L4-5, there is a broad-based right paracentral and intraforaminal disc protrusion, producing
narrowing of the right L4-5 neural foramen, and possibly accounting for right L4 radiculopathy. The
disc protrusion extends in the true lateral recess, and could potentially account for right L5
radiculopathy as well. There is overall minimal central spinal stenosis, of doubtful significance.

There is mild circumferential disc bulging at L5-S1, with no clear evidence of neural compression
Based on the last MRI, the neurosurgeon I saw does not think that I need surgery(he checked my last MRI against the done from 3 years ago and they are very similar) and he cannot explain my left leg symptoms now and not being able to walk normally. Most likely he said I had a compression on the left lateral L5 that caused my current symptoms, but apparently that compression is been resolved. Still I have the foot drop and my left hip sinks while ok (ok while standing).
I have done a NCV test (referred for foot drop) which showed peroneal nerve conductivity as normal and EMG test that showed weak anterioar tibia. Also the neurologist does not think I need surgery right now and wants to wee my again in coupe, of months.
Questions:
1. Related to the weakness in my left hip and not being to keep up the hip(weak glutes medium/min?!) – do you think this can be fixed with surgery?
2. In case of nerve root damage, the nerve is done from the farthest point(foot) back to spine or other way? – I am trying to figure out the potential time for recover of the gluteal nerve ; is any indication of this based on the peroneal nerve conductivity being normal?
3. What other options do I have ? – I am training myself almost every day with glutes exercises, but I feel I am not progressing too much lately.
4. Ultimately, is my condition of not being to walk recoverable(I have no pain, just my hip sinks – I also used 4 months a cane, now I am cane free, but not being to walk normally).

Thank you

Donald Corenman, MD, DC
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April 14, 2014 at 6:10 am

Post count: 8660

#10712

You unfortunately had a disc herniation that caused enough compression of the nerve root to affect the motor portion of the nerve root (weakness). The left weakness with this report makes me think there is a far lateral disc herniation on the left that was missed. Your symptom history is consistent with an acute herniation but there are some rare conditions that can attack a nerve without compression (mononeuritis).

The report “At L4-5, there is a broad-based right paracentral and intraforaminal disc protrusion, producing narrowing of the right L4-5 neural foramen, and possibly accounting for right L4 radiculopathy. The disc protrusion extends in the true lateral recess, and could potentially account for right L5 radiculopathy as well. There is overall minimal central spinal stenosis, of doubtful significance” does not focus on left pathology.

Your symptoms indicate an L5 radiculopathy “I could not keep my left hip up and developed some sort of foot drop (could lift the foot with big toe, but no heel walking”. The anterior tibial muscle is the one that keeps your foot up and is either L4 or L5 but the big toe extensor (EHL) is always L5 and you probably have a trendelenberg gait due to weakness of the gluteus medius. When you step on your leg, the pelvis on the opposite side wants to drop. What keeps the pelvis up is the gluteus medius muscle. Weakness of this muscle causes a limp.

You also have to consider nerve regeneration and recovery. Surgically taking the compression off the nerve late (no one knows how long a nerve can be compressed but the shortest time has the best chance of recovery) will have less chance of recovery. See the section “Nerve damage and healing” to understand how a nerve heals with or without decompression.

Therapy now is probably the best modality for recovery but I always recommend decompression if the nerve is still compressed and there is motor weakness. The reason you have left sided weakness makes me think you should have another radiologist read your MRI films and suggest looking for this herniation.

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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Donald Corenman, MD, DC

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Eric S

Sep 25, 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 10, 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 8, 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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