How much pain is enough?

Tagged: microdisc surgery

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erictennis
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May 29, 2016 at 2:23 pm

Post count: 4

#22279

Hi Dr. Corenman, thanks for being so engaging with the general public by supporting this forum. I think everyone involved is very appreciative. Your book was also very informative, btw.

I have a 3mm right paracentral L5/S1 HNP that hasn’t changed much since 2009 (I’m in my 40’s; I got that MRI for a different reason). In March I felt a “slip” or “give” while extending for a backhand in tennis. Since that event (MRI comments are below) I’ve been undergoing P.T. (e.g., trigger point release + core strengthening) and chiro decompression to manage it. Discogenic pain decreased in the first week. What remained was moderate sciatica extending down to the knee – triggered by certain sitting postures – and entering/exiting vehicles, with infrequent tingling in the foot.

Last week I was extending to retrieve a short ball in table tennis, and felt the same kind of “give”. Since then, I’ve had severe sciatic pain in the same postures (but not when standing/lying), taking a pain killer (hydrocodone), and plan on getting an injection in the next week or so.

Could these “slips” be additional NP protruding and exerting added pressure on the nerve root? I got a couple of opinions from local surgeons (I only saw their P.A.’s), and both said I shouldn’t consider surgery at this point. But I feel like my disc is telling me it’s time to care of the problem instead of continuing the cycle of slip/traction/trigger point release/medication/etc (I had to cancel a cruise because of this). I hear stories about surgery and “you will never be the same”, but your book has given me confidence in modern surgery and its efficacy. Do you find low re-herniation rates with modern-day techniques? I feel that my disc (not as concerned about L4/5 at this point) is on the edge; the injection may move it a bit further away, but eventually another “slip” is inevitable (e.g., every tennis backhand is a risk); and in that case, it’s enough pain for me.

Many thanks.

Here is the MRI report, if interested:

MRI Date: 2/2016
COMMENTS:
At the L4-L5 level, there has been no significant change compared to November 9, 2009, 4 mm slightly right paracentral disc extrusion was seen previously and is not significantly changed. There is mild narrowing of the right lateral recess With no definite contact of the proximal transiting right L5 nerve root. Mild bilateral facet degeneration is also unchanged.
At the L5-S1 level, 3 mm right paracentral disc protrusion is also unchanged Compared to November 9, 2009 with unchanged narrowing of the right lateral recess and unchanged approximation of the disc protrusion to the right S1 nerve root. Mild degenerative facet arthropathy is also unchanged.

At the level of L4-L5, no significant change from prior exam. Again demonstrated is a 4 mm right paracentral disc extrusion that migrates slightly inferiorly and indents the ventral theoal sac. There is mild narrowing of the right lateral recess with no definite contact of the right L5 nerve root. There is mild canal stenosis. Mild bilateral facet hypertrophy with thickening of the ligamentum flavum. Mild narrowing of both neural foramina.
At the level of L5-S1, no significant change from prior exam. Broad-based 3 mm right paracentral disc protrusion is again demonstrated which appears to contact the transiting right S1 nerve root. There is slight indentation of the ventral thecal sac with no canal stenosis. Mild bilateral facet hypertrophy. Mild narrowing of the right greater than left neural foramen.
Paravertebral soft tissues are unremarkable. Visualized intra-abdominal contents are within normal limits.

IMPRESSION:
No significant interval change compared to prior MRI of the lumbar spine, dated December 20, 2011, demonstrated small disc herniations at L4-L5 and L5-S1.
The small disc protrusion at the L5-S1 level appears to contact the transiting right S1 nerve root, possibly resulting in right S1 radicular symptoms.
Mild degenerative facet arthropathy at L4-L5 and L5-S1.

Donald Corenman, MD, DC
Moderator

June 4, 2016 at 11:14 am

Post count: 8660

#22318

The “slips” are most likely further disc protrusions based upon your increased leg pain. Herniated disc nerve leg pain generally occurs with sitting and bending and is relieved by standing.Very critical evaluation might indicate a very slight change is position that was not appreciated. The “slip” could also have stretched the nerve root over the herniation which would possibly show a swollen root.

Most likely, the pain originates from the S1 root so a SNRB (selective nerve root block) probably does not have to be done but with any question, one should be considered.

Recurrent disc herniation occur at about a 10% rate no matter what you do (surgery or no surgery). The current surgical techniques are very clean generally and have good success rate. The surgeon obviously has to be technically proficient and meticulous.

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.

erictennis
Participant

June 5, 2016 at 12:54 pm

Post count: 4

#22327

If continued conservative treatment fails, would Nucleoplasty Percutaneous Discectomy be an option (my HNP is about 4mm)? Do you have experience with this procedure?

Donald Corenman, MD, DC
Moderator

June 6, 2016 at 7:49 am

Post count: 8660

#22332

Nucleoplasty or Percutaneous Discectomy is not an option. These procedures are performed blindly and attempt to empty the disc space without addressing the extruded disc that is compressing the nerve root. These procedures became popular about 10 years ago but have been demonstrated to be ineffective for most disorders.

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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81 reviews

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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