Help! Effectiveness of prior surgery without disc removal?

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Purduejaime
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November 13, 2012 at 12:22 pm

Post count: 6

#7389

Dear Doctor,

I need help determining if a second surgery might be of any help to me or if I should remain a chronic pain patient my whole life! I’m only 31!!!

I am a 31 year old former figure skater who had a pars defect that turned into Grade 2+ Spondylolisthesis. In 2002, at age 21 I had a posterior only fusion WITHOUT disc removal using 4 pedical screws and autograft from iliac crest. At the time of surgery, I got 90 percent of pain relief from radiating pain, and 75 percent low back pain relief.

Since that time, after about 4 months to two years post surgery, the low back pain began increasing in frequency and quality. It was worst when sitting or standing for any length of time. Also, ive had chronic muscle spasm knots in low back since 2 years post-op. At 12 months and two years post-op, I had imaging done that showed normal post-fusion changes and successful fusion. At 2 years post-op, I went to visit a pain management doctor, after the surgeon determined it is possible remaining pain is from disc left in (disc was only bulging at time of fusion, was not standard protocol in 2002 to remove). I Was unwilling at that time to consider further surgery.

Since that time I’ve had SI injections, epidural injections, and been on 9 years of short-acting narcotics. In 2011, I gave birth to my son, and since that time, I’ve had increasing SEVERE pain at all hours of day and cannot stand or sit for any length of time. The only semi-relief I get is while laying down, but the actual motion of laying down is EXCRUTIATING. It feels as if my whole back is shifting into different place and is painful for two minutes then let’s up.

Imaging studies I’ve had since birth of my son show increased mild osteophytes and arthritis, increased kyphosis in thoracic spine, mild spondylolisthesis in l5 (is this normal, has never been recorded before?), post-fusion changes, and of course the disc between L5s1 is very very sick thin and black. In response to these imaging, I had RAF procedure on left side and have actually been in extreme pain since this as muscles responded with increased spasm. So, arthritis doesn’t seem to be cause of spasm? I’ve also had massage, chiropractor care, traction (felt best of anything) and PT since having him.

I’m in line to speak with a spine surgeon, but I would very much appreciate another opinion!! Do you think it is possible my pain has been caused by dying disc that was potentially moved during delivery of son? Do you think additional surgery could have a potential beneficial outcome? I do not want to be disabled and become a lifetime chronic pain patient (although I am right now) and have to go on longer acting meds. However, I have always heard that 2nd surgeries are not very successful. Also, do you think upper back numbness from kyphosis is related at all to the fusion in my lower back?

Anyhow, I apologize for the length, but I hope I’ve provided you with enough necessary information to tell me whether I may be a candidate for surgery or other procedures (Botox etc). One parting thought…. The ONLY time I’ve been pain FREE since 1996 was when I had the epidural to have my son. I am in so much pain I begged for constant epidural at the cost of using my legs, which of course has been declined.

Thank you, Jaime

Donald Corenman, MD, DC
Moderator

November 13, 2012 at 5:48 pm

Post count: 8660

#7392

A grade II+ spondylolisthesis does not respond well to a posterior only fusion with instrumentation but at the time of your surgery, the posterior fusion was the procedure of choice for many surgeons. The first suspicion I have is that the surgery did not create a solid fusion. Most patients who had undergone fusion with good relief for only a short period of time (in your case four months to two years) have a potential for a non-fusion (pseudoarthrosis). I am suspicious of the imaging a year down the road that indicates solid fusion.

You indicate “mild spondylolisthesis” of L5. I am unclear if you mean the L4-5 level or residual slip of the L5-S1 level. If the L4-5 level is slipped, this most likely is a degenerative spondylolisthesis (see website), a common problem for females and a common spinal pain generator.

Has the disc at L5-S1, the prior fusion level changed in appearance since your initial fusion so many years ago? Normally, a posterior fusion at L5-S1 will “freeze in time” the appearance of this disc as the fusion “unloads” the disc. A change in the disc appearance leads to suspicion of motion and loading of this disc space regardless of the fusion status.

You need a complete work-up including a CT scan and MRI (on good scanners) and a diagnostic work-up from a meticulous and experienced spine surgeon.

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.

Purduejaime
Member

November 19, 2012 at 2:51 am

Post count: 6

#7449

Oh my goodness!!! I want to thank you Dr. Corenman!!! You’ve thoroughly answered the questions I have (given the constraints) and told me things no doctor has told me before! I cannot tell you how much I appreciate your advice and the time you took!

In regards to your further questions, the recent films I’ve had (flex and extension X-rays and mri w/ and w/out) show mild Spondylolisthesis at L5/s1 and nothing wrong at the next level up. In regards to your disc question, YES a change has happened! Over the years I’ve had imaging, my disc has gone from bulging (at time of fusion) to nearly completely black and compressed! I had NO IDEA that the disc was supposed to stay the way it was, ie frozen in time!!

So, even though the X-rays don’t show movement, could there still be movement?

Thank you again for these answers. I’m optimistic that I could have helpful treatment for the first time in a decade!

Donald Corenman, MD, DC
Moderator

November 20, 2012 at 12:36 am

Post count: 8660

#7455

The change in your disc appearance over time most likely indicates a non-solid fusion. Flexion/extension x-rays do not have to demonstrate gross motion for a non-union to be present but there are subtle signs that can indicate motion without measurable motion being present.

See if you can ask your current doctor for a CT scan of the L5-S1 segment. The scan should be on a 64 slice or 128 slice scanner for the best accuracy.

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.

Purduejaime
Member

November 29, 2012 at 7:41 am

Post count: 6

#7495

Dr, I just want to again thank you for your help! I saw a spine surgeon today and he told me immediately (with no examination and short history taken by the nurse) that he didn’t see anything he could help me with on my MRI. I was immediately in tears because that was the answer I feared the most.

Because of your responses, I was able to ask him about the possibility of movement in my fusion and he ordered CT and Xrays. I had the xrays done today and because I’m not a doctor or radiologist I don’t know if the appearance of movement between the vertebrae is just a trick due to the change in angle from laying to standing.

Could you please take a look at these xrays to see if it is apparent at all. Also, I really wish that you lived near the area where I live because you are doing a great service to people through this. (I sent the pictures by email).

Jaime

Purduejaime
Member

November 29, 2012 at 8:27 am

Post count: 6

#7496

ALSO, in addition to above text, the spine doctor I saw said that the reason why my disc is degrading so much is because it is not being used. Is that possible?
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Donald Corenman, MD, DC

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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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