Granulation Tissue Explanation

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BirdBackPain
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June 2, 2014 at 8:37 am

Post count: 7

#10930

Dr. Corenman,

You are correct, initial herniation, then a decompression in March, then a recurrent herniation confirmed end of May. Thank you for your opinion, hopefully I can get your opinion on a couple more items.

From your experience, how is the recovery of the 2nd micro compared to the first?

From the surgeons perspective is it easier or more complex?

Does the Lamina hole get bored out to a larger diameter or is the surgeon able to get into the disk with out any further bone disruption?

Is there less soft tissue disruption the second time around?

Thanks Dr for your time,

Bird

Donald Corenman, MD, DC
Moderator

June 2, 2014 at 10:22 pm

Post count: 8660

#10932

The recovery from a second microdiscectomy should be similar to the first. The second surgery is more complex than the first as scar is present. More care needs to be used to free the nerve and remove the herniation. The laminotomy (lamina hole) generally is enlarged about 3mm as the surgeon wants to be in non-scar territory and move from “normal tissue” into the scar zone to protect the nerve. In general, there is less soft tissue disruption the second time.

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

June 3, 2014 at 10:37 pm

Post count: 7

#10939

Thanks again!

What about scar tissue the second time around? I would assume since there is less soft tissues being disrupted then the second time would not scar as much?

What are your opinions on growing thicker scar tissue the second time around?

Thanks Doctor.

Donald Corenman, MD, DC
Moderator

June 4, 2014 at 2:13 am

Post count: 8660

#10945

Scar tissue occurs in every surgery and generally even in every injury (even without surgery). Scar would occur after this second surgery and be somewhat more significant than after the first surgery. Still, this scar tissue does not seem to be causing your symptoms but the recurrent herniation is. Removal of this herniation should relieve your current nerve pain.

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

June 28, 2014 at 12:06 am

Post count: 7

#11106

Dr,

1) I have a spot to the left of my incision site that hurts badly when pressed with even a little bit of force (not a skin pain, a deep pain). When getting a massage when that spot is hit it sends a shock wave of pain into my tailbone and the surrounding incision tissue. At first I thought it may be seroma related and it was somehow pressing on my nerve but after going over my 2nd MRI report it mentions at the very bottom “There is a soft tissue enhancement predominantly in the left lateral aspect of the posterior paraspinal soft tissues at L4-5 and L5-S1.”

Do you think that could be causing the problem?

2) I received my surgery report and found some things that my Dr never told me about, I was wondering if you could tell me if its important or not. Part of report shown below.

“There was erosive facet pathology also noted with synovial facet cyst formation across this zone, which was resected and removed using microdissection technique, releasing some tethering around the S1 nerve root.”

This sounds to me like I had a cyst & nerve tethering? I would assume nerve tethering would be scar tissue possible from the original herniation? Will the cyst grow back?

3) One more thing that strikes me off is in the MRI report shown below.

Is it common for the surgeon to make two cuts into the disc. The wording to me sounds like there were two different tears in the disc.

1st MRI after surgery, no contrast.

[L4-5] 4.5 mm disk bulge with posterocentral and left paracentral annular tear and 7.6 mm caudal soft tissue intensity, extruded disc versed post-operative granulation effacing left lateral recess with possible indentation on the descending left L5 nerve root. Mild right and moderate left neural foraminal stenosis due to disc osteophyte
complex. The midline AP dimension of the thecal sac measures 11.4mm.

[L5-S1] Disc desiccation with moderately reduced height. 4mm disc bulge with posterocentral and left paracentral annular tear and 5 mm disc protrusion along with marginal ostephyte and facet arthrosis producing moderate bilateral neural foraminal stenosis. The midline AP dimension of the thecal sac measures 10.3.

2nd MRI after surgery, with contrast

[L4-5] The previously described 7.5mm soft tissue density 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 and extruded disc and recurrent disc herniation. It appears to be contiguous with the L4-5 disk. There is a focal fluid collection at the laminectomy site measuring approximately 1.5 x 2 cm without significant enhancement in the post contrast images. This likely represents a seroma. There is a disc osteophyte complex with ligamentum flavum and facet joint hypertrophic changes causing moderate right and severe left neuaral forminal narrowing. The Ap diameter of the spinal canal is 1.3 cm.

[L5-S1] There is a stable broad-based posterior disc osteophte complex with ligamentum flavum and facet joing hypertrophic changes acsuing moderate bilateral neural forminal narrowing. The AP diameter of the spinal canal is 1.3 cm. There is a soft tissue enhancement predominantly in the left lateral aspect of the posterior paraspinal soft tissues at L4-5 and L5-S1.

Thank you for your wisdom and knowledge.

Bird

Donald Corenman, MD, DC
Moderator

June 29, 2014 at 3:55 am

Post count: 8660

#11109

Sensitivity of the incised and healed skin after a surgery is not that uncommon. There are very small sensory nerves that can be aggravated after the incision heals and can be that way for six months. Local tenderness will eventually go away. There are therapists that might use “overstimulation” training. That is-massage rapidly and lightly to try and desensitize this nerve.

Injection in this area with lidocaine and steroid might be helpful also.

The surgical report noted a cyst of the facet (ganglion or synovial cyst) which is common but should have been seen and expected by looking at the MRI. If the MRI was of poor quality, this cyst might not have been seen. The tethering of the root is an adhesion which is quite common in the presence of a facet cyst as these cyst walls are very sticky.

The cyst can grow back with about a 10% recurrence rate.

The surgeon normally does not have to cut the rear wall of the disc as the disc wall has already torn to allow the herniation to occur in the first place. He or she might have to make an incision in the PLL (posterior longitudinal ligament) if the disc fragment is trapped under this structure.

You have had a previous microdisectomy at L4-5 with what is reported as a recurrent disc herniation at this same 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.
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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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