[kellyg]

#31879

My 16 year old daughter is suffering with complications after her
L5/S1 pars defect repair surgery three years ago. The surgery was
performed in Jan 2017 after a bilateral pars defect and
spondylolisthesis were diagnosed. Her main symptom going into
surgery was continuous back pain worse upon standing, walking, any activity and bending backward.
During surgery two screws were put in place – one on each side – to
repair this fracture. Additionally, the surgeon roughed up the ends
of the fractured bone, took a bone graft from her iliac crest, and
used Medtronic Infuse BMP small packet to ensure that the fracture
would heal. Initially after surgery, her pain seemed to get better.
But shortly after (a few months) pain returned and worsened with time. We went back to
initial surgeon after a year – he took x-rays and MRI and said it
looked like she had facet hypertrophy in the L4/L5 segment above the
screws. He saw degeneration and said the next step would be spinal
fusion but there was no hurry – our actions should be dictated by her pain. So we decided to wait.

After another year of lower back pain (2 years post-surgery) we
decided to get a second opinion. We went to another orthopedic spine
surgeon. He took a CT scan, xrays and previous MRI. He said the
facet joints are very arthritic. The body has attempted to heal
these arthritic joints by creating extra bone. He also said the
joint itself where the pars defect was no longer has cartilage. He
thinks the joint surface is no longer viable and the only course of
action would be spinal fusion. Again, no hurry, just advised to act
on it when pain became too much. So we waited again.

Another year passes – we see a chiropractor, a pain management
specialist, and got PRP injections in the area. Nothing helps. We
go see a third spinal orthopedic surgeon who takes another MRI and also does a Spect CT.
He says she has heterotopic ossification likely caused by original surgeon using both
BMP & Iliac bone crest. He does not see arthritis or any other
damages to the area. He doesn’t see any other reason for the pain,
and thinks through surgery he can removed the ectopic bone growth and
that likely her pain will be helped. He says there is so much bone
growth that her spine is being tethered and unable to move correctly, which will also lead to additional problems down the road. The surgeon has not been presented with this same situation before (of the ectopic bone growth) but has removed extra bone spurs etc. and is confident in her case, there are not extra nerves and pain generators where the bone growth is located, so It should be a successful surgery.

We are scrambling to make sense of these differing opinions. We have
hope that the ectopic bone can be removed, but do not see much of
anything about this actually being done successfully – and we
certainly don’t want to make anything worse. We are hoping you can review her case and give us a second opinion and also share your experiences with ectopic bone growth removal.
Thank you for your time and providing this service.

[Donald Corenman, MD, DC]

#31896

“My 16 year old daughter is suffering with complications after her L5/S1 pars defect repair surgery three years ago”. She developed lower back pain sometime after the pars repair. You then note:

“After another year of lower back pain (2 years post-surgery) we decided to get a second opinion. We went to another orthopedic spine surgeon. He took a CT scan, xrays and previous MRI. He said the facet joints are very arthritic. The body has attempted to heal these arthritic joints by creating extra bone. He also said the joint itself where the pars defect was no longer has cartilage. He thinks the joint surface is no longer viable and the only course of action would be spinal fusion. Again, no hurry, just advised to act on it when pain became too much. So we waited again”.

“Another year passes – we see a chiropractor, a pain management specialist, and got PRP injections in the area. Nothing helps. We go see a third spinal orthopedic surgeon who takes another MRI and also does a Spect CT. He says she has heterotopic ossification likely caused by original surgeon using both BMP & Iliac bone crest. He does not see arthritis or any other damages to the area. He doesn’t see any other reason for the pain, and thinks through surgery he can removed the ectopic bone growth and that likely her pain will be helped. He says there is so much bone growth that her spine is being tethered and unable to move correctly, which will also lead to additional problems down the road. The surgeon has not been presented with this same situation before (of the ectopic bone growth) but has removed extra bone spurs etc. and is confident in her case, there are not extra nerves and pain generators where the bone growth is located, so It should be a successful surgery”.

Pars fractures can be difficult to get to heal. The repair process typically includes fixation across the fractures, uses iliac crest bone and uses bone morphogenic protein (BMP) to get bone to grow across the fracture defect. This BMP protein can cause heterotopic ossification (bone growth in areas not designed to have bone formation) which in this case can be a desired effect as long as the additional bone grows in the appropriate location and does not cross boundaries that can cause unwanted bone formation.

I have repaired about 40 pars fractures and have about a 5% rate of bone formation in areas that caused problems such as unwanted facet fusions and osteophytic “bumps” that had to be removed. I am apprehensive about your second and third opinions. One surgeon talks about facet arthritis (loss of the articular cartilage) and another discusses only heterotic bone formation causing impingement syndrome.

I will assume that the fracture fragments have healed and this discussion is not about nonunion. Also, I assume the MRI notes normal discs and this is not a degenerative disc disease discussion.

Both facet arthritis and hetertopic ossification can cause lower back pain. The pain can occur from the facets at the pars fracture level (L5-S1) or from the level above (L4-5). In this case, I would need to see the imaging studies both before and after the repair as the possibilities for pain generation will depend upon the current anatomy and heterotopic bone formation location.

Please contact my office.

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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