Granulation Tissue Explanation

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BirdBackPain
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May 23, 2014 at 5:26 am

Post count: 7

#10883

First off, thanks Dr. Corenman for having a wonderful forum such as this.

I have a question about the term granulation tissue in relation to a lumbar MRI report. This particular MRI was from 5/12. I don’t have my report on me but it read to the effects of “7.5MM Caudal soft tissue intensity, extruded disk vs post op granulation possibly indenting on left L5 nerve root.”
The PA for my surgeon says that it is possible to be just inflammation from my surgery 11 weeks ago (MicroD L4-S1) but mostly everything online basically says that granulation tissue is built up scar tissue. In a post here you mention granulation to be “healing tissue.”
Where is the line in the sand so to speak of when granulation tissue turns into scar tissue that may bind, compress or be tethered to nerve root?
I went in today and had a contrast MRI performed and I have the MRI disk but I am unable to see where the tissue could be built up. I can see bulges on the sagittal images but I cannot make out anything weird in the axial ones. Would the material pressing upon nerve be light colored or dark with the contrast?

Thanks you in advance,
Bird

Donald Corenman, MD, DC
Moderator

May 27, 2014 at 6:04 am

Post count: 8660

#10892

Granulation tissue is made up of white blood cells, platelets, myofibroblasts and other cells that are designed to remove debris and form scar. Most of the time, the scar tissue formation is minimal with no significant consequences. Some individuals for reasons yet to be understood, form significant amounts of this granulation tissue.

This tissue can be inflammatory which is quite irritative to the nerve root or compressive (causing similar effects as a disc herniation). Most of the time, over time this tissue will shrink down and the nerve will calm down. For these patients, I do use an epidural injection as steroid reduces swelling and reduces the ability of this granulation tissue (remember white blood cells) to cause irritation.

Now-a recurrent disc hernation can occur and then be surrounded by granulation tissue. This will show a “dark spot” in the middle of the highlighted area (on a T1 post-gad image). Look at the axial T1 images that are before and after gadolinium as gadolinium is white on these images and outlines the granulation tissue (it lights up).

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.

BirdBackPain
Member

May 30, 2014 at 5:40 am

Post count: 7

#10907

Thanks for the explanation, I hope more people get to see this explanation as it is the best that I have found yet.

I received my MRI results with the contrast yesterday. Some good news, some bad. I was wondering if I could get your take on it and answer a couple more questions.

L4-5

The previously described 7.5 mm soft tissue intensity is again noted in the left lateral aspect abutting the left L5 nerve root. It shows rim enhancement in the post contrast images and likely represents an extruded disc and recurrent disc herniation. It appears to be contiguous with the L4-5 disc. There is a focal fluid collection at the laminectomy site measuring approximately 1.5 to 2 cm with out significant enhancement in the post contrast images. This likely represents a seroma. There is a disc osteophyte complex with ligamentum flavum and facet join hypertrophic changes causing moderate right and severe left neural foraminal narrowing.

The good I guess is its not scar tissue. After seeing this my doctor still went ahead with ESI. I expressed my concerns but he said if would be impossible for him to hit and if he did hit it it would not matter.

My question is what would be your next step for the seroma?

Also, in your opinion, now that its a know herniation what would be your next plan of attack?

Thanks Dr.

Donald Corenman, MD, DC
Moderator

May 30, 2014 at 10:17 pm

Post count: 8660

#10908

You have a recurrent disc herniation. This is not uncommon with a frequency of about 10%. You also have a seroma which is also not uncommon. The seroma is of no matter as it does not compress the nerve root ans should absorb away over time.

The question is the recurrent disc hernation. Again, you need to go back to the basic indications for surgery for a disc herniation. The three indications are motor weakness, bowel and bladder involvement and intolerable pain.

I assume you do not have motor weakness or bowel and bladder involvement as this is unlikely. This brings us to pain tolerance. I generally have patients undergo further epidural injections and some PT. If the pain is controlled and decreasing, I continue down this path. If the pain is not tolerated, a repeat microdiscectomy is considered.

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.

BirdBackPain
Member

May 31, 2014 at 3:32 am

Post count: 7

#10915

Man, with odds like that I hope the other 9 people who had surgery are happy :)

I am glad you think the seroma will absorb over time. I had a hunch that I had a build up of something in that region because there was a certain spot near incision that when touched would shoot sciatic pain into my gluts. This has since stopped so maybe it has already been absorbing.

The reason I ask what your next step would be is because the PM Doctor thinks that my Surgeon would only do a fusion next. I have an appointment with him in a couple weeks to discuss solutions.
More than likely I will just live with the pain and try my best to avoid another surgery.

Thank you very much for your time and knowledge.
Take care,

Bird

Donald Corenman, MD, DC
Moderator

May 31, 2014 at 7:59 am

Post count: 8660

#10916

The reason for fusion after a recurrent disc herniation is only after three total herniations have occurred. My understanding is that you have only had the initial herniation, microdisectomy and then recurrent herniation. This makes two herniations and therefore you would only need a repeat microdisectomy.

If a surgeon is suggesting a fusion, a second opinion would be wise. That is assuming that surgery might be 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.
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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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