Herniated Disc at L4-L5 and L5-S1

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HezWag
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September 24, 2011 at 12:00 am

Post count: 2

#4918

Hi Dr Corenmen,

I have a few questions hopefully you can help me with. I have had this back pain since an injury at work on April 26th of this year. I have undergone about 4 months of PT, have had 2 ESI’s, and I am still in constant pain. I have metal in my chest so they will not do an MRI, however I have had a CT scan in June that showed a 1mm herniation at L4-L5 and a 4mm herniation at L5-S1. I have experienced non-stop horrific pain in my back as well as in my left buttocks going down my left leg. Originally I did not have any weakness, but this has developed in my left leg for the last 2 months. I did not receive much reduction in pain from the epidural steroid injections. From the 1st injection I did get minimal relief in the leg pain for about 1 week. Since the second injection I have had an increase in pain as well as a non-positional headache for the last week. Is this a normal occurance?? My doctor doesn’t seem to think it is related, however he hasn’t seen me, I have just talked to his nurse on the phone.

My second question is, is a 1mm and 4mm herniation enough to warrant surgery?

Lastly, because this is a worker’s compensation case I have not yet seen a spine specialist, just a Physiatrist. Is this also the normal situation? I am worried about permanent nerve damage because I now walk with a limp. I am only 31yrs old and this concerns me.

Thank you for your time

Donald Corenman, MD, DC
Moderator

September 24, 2011 at 4:22 am

Post count: 8660

#4919

You had a back injury about 5 months ago at work that apparently has not improved at this point. Your pain is lower back and well as left buttocks down the leg. You have had a CT scan without a myelogram that demonstrated a 1 mm HNP at L4-5 and a 4 mm HNP at L5-S1.

Let’s start at the beginning. What is the percentage of your pain in the lower back vs. the buttocks and leg? 60/40, 70/30, or the reverse? What makes your pain better and worse? Walking, standing, bending, sitting, lying down? You note weakness in your left leg. It is because of pain inhibition or true weakness (can’t get the muscle to fire with or without pain)?

What side is the larger disc herniation spotted by CT scan? Did you get temporary relief from the epidurals (the first 2-3 hours) or was that time period data not recorded (pain diary- see website).

Where is your headache after the epidural? Front of the head, eyes, back of the head, base of the neck?

I need more information.

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.

HezWag
Member

September 24, 2011 at 9:50 am

Post count: 2

#4920

Dr Corenman,

I now have the CT interpretaion in front of me and I will type out what it says:

At L4-L5 there is a minimal annular disk buldge measuring 1-1.5mm.
At L5-S1 a central broad based herniation measures up to 4mm in thickness. This extends predominantly into the ventral epidural space.

I would say the percentage of pain is approx 60-40 with the most of it being located in the back. My pain is worse by doing anything for an extended period of time. Sitting, standing, or lying down. To this point if I sit too long I need to stand and so on. When the doctor tested my strength and ability to hold my leg up against pressure I am now unable to do so. No matter how hard I try I can’t hold resistance against pressure. As well as the limp in the left leg. I did not get any relief within the first few hours after the injection. The minimal relief occured about 4-5 days after the injection and lasted approx 1 week.

The headache is located more towards the front of the head and is throbbing in nature. It is also non-positional, so I am aware that this is probably not a spinal headache.

Thank you for your time

Donald Corenman, MD, DC
Moderator

September 24, 2011 at 1:45 pm

Post count: 8660

#4923

OK- you have mostly lower back pain and that pain is increased with any mechanical maneuvers. The CT scan does not give great information on the health of the disc. It may appear that your L5-S1 disc is more degenerative than the L4-5 disc based upon the disc bulge. This may be more advanced than you can ascertain but do any of the endplates have fractures in them?

The weakness of lifting of the leg I will assume is when you are lying on your back and lift your leg up at the hip joint (flexion of the hip). You cannot resist the downward pressure of the doctor’s hand on your thigh. This is a result of weakness of the psoas muscle and would not be related to disc degenerative changes in the lower lumbar spine as the psoas muscle is innervated by much higher up nerve roots.

This back injury at 5 months of age is not improving. I hope you have already gone through a core strengthening program and Pilates. If not- that is your next stop.

The headache does not sound like dural irritation from the injection but from something else.

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 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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