Incomplete Spinal Fusion

Tagged: failed back surgery syndrome, Incomplete Fusion lumbar spine

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Donald Corenman, MD, DC
Moderator

November 12, 2017 at 7:54 am

Post count: 8660

#26811

Sounds like you are having the typical good recovery from your revision surgery. It should take some further time for full fusion unless BMP was used (in which case you might be solidly fused now). Once you get better strength and range of motion, you will continue to improve.

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.

sperryguy
Participant

April 18, 2018 at 9:28 am

Post count: 68

#28088

Hi Dr Corenman

Been awhile since I posted my recovery. Been almost a year since my revision L4/S1 surgery. Some issues, nothing horrific. slow recovery but still way better than before the procedure. This is the latest MRI. Any suggestions or questions when I meet with the surgeon in May? Thank you so much for all the help! Steven
Impression

IMPRESSION:

Prior laminectomy at the L4 and L5 levels. Prior anterior and posterior fusion at the L4-L5 and L5-S1 levels. No evidence of loosening of the hardware.

L3-4: Circumferential bulging of the disc annulus, facet arthropathy, and ligamentum flavum prominence causing mild to moderate canal and bilateral lateral recess stenosis. Stable superimposed small left intraforaminal disc herniation causing flattening of the exiting left L3 nerve root.

L5-S1: Postoperative changes are noted. Prominent left paracentral and left intraforaminal soft tissue density, the extent of which has increased compared with the soft tissue intensity on the MRI lumbar spine dated March 8, 2017. If clinically indicated, contrast-enhanced CT or contrast-enhanced MR imaging with attention to the L5-S1 level is recommended for further evaluation.
Narrative

CLINICAL INDICATION: Low back pain. Prior lumbar spine fusion surgery.

TECHNIQUE: CT of the lumbar spine was performed without the administration of intravenous contrast, according to standard protocol using multidetector helical technique. Sagittal and coronal reformations were obtained.

COMPARISON: MRI lumbar spine dated March 8, 2017.

FINDINGS:
The lumbar lordosis is maintained. There is a mild levoscoliosis. There is no fracture or cortical destruction. No focal suspicious osseous lesions are noted. No prevertebral mass is seen.

Prior anterior and posterior fusion at the L4-L5 and L5-S1 levels is seen. Prior laminectomy at the L4 and L5 levels is seen. Transpedicle screws in L4, L5, and S1 are noted. The left-sided screw in S1 extends 2 mm beyond the anterior cortical margin of S1. Paravertebral rods are noted. Interbody cage placement at the L4-L5 and L5-S1 levels is noted. Dorsolateral bone graft at the L4-L5 level bilaterally is seen. There is no evidence of loosening of the hardware. Partial osseous integration is seen. Postoperative granulation tissue is seen. Postoperative changes in the left iliac bone are noted. There is a focus of increased CT density in the left iliac bone without cortical destruction or pathologic soft tissue mass; differential diagnosis includes, among others, focal fibrous dysplasia and Paget disease.

EVALUATION OF INDIVIDUAL LEVELS DEMONSTRATES:
L1-2: No significant canal or neural foraminal stenosis.

L2-3: No significant canal or neural foraminal stenosis.

L3-4: Circumferential bulging of the disc annulus, facet arthropathy, and ligamentum flavum prominence causing mild to moderate canal and bilateral lateral recess stenosis. Stable superimposed small left intraforaminal disc herniation causing flattening of the exiting left L3 nerve root.

L4-5: Postoperative changes are noted. No significant canal or neural foraminal stenosis.

L5-S1: Postoperative changes are noted. Prominent left paracentral and left intraforaminal soft tissue density, the extent of which has increased compared with the soft tissue intensity on the MRI lumbar spine dated March 8, 2017. If clinically indicated, contrast-enhanced CT or contrast-enhanced MR imaging with attention to the L5-S1 level is recommended for further evaluation.

sperryguy
Participant

April 20, 2018 at 11:26 am

Post count: 68

#28093

Correction, this is a CATSCAN.

Donald Corenman, MD, DC
Moderator

April 21, 2018 at 10:02 am

Post count: 8660

#28099

OK. This is a better report than the pseudoarthrosis that you originally had however this radiologist did not comment on fusion status which is generally why a CT scan is ordered.

You are developing breakdown of the level above the fusion at L3-4 (“Circumferential bulging of the disc annulus, facet arthropathy, and ligamentum flavum prominence causing mild to moderate canal and bilateral lateral recess stenosis”). This level may become a problem in the future.

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.

sperryguy
Participant

April 24, 2018 at 9:18 am

Post count: 68

#28131

Hi Dr Corenman

My PT had the same question, why no mention of a fusion? That is concerning. My Pain management doctor was concerned and unclear as to the mention of “soft tissue intensity” issues. He doesn’t understand what the radiologist is trying to communicate. The past few weeks the lower back from left to right is quite painful and stiff, despite being quite active. I have been experiencing way more issues with leg pain. to fill in some blanks, I have had 2 RFA’s L4-L5, and L3-L4, both of which helped. Logic would dictate that these procedures would no longer be required after this surgery. I was warned that the L3-L4 may have issues. I simply had no options due to being in so much pain and couldnt function. Is it possible the scar tissue is an issue? Do I have options having that removed? If i need an additional surgery on L3-L4 what should I expect considering the revisions? Thanks again….!!

Steve

Donald Corenman, MD, DC
Moderator

April 24, 2018 at 10:11 am

Post count: 8660

#28132

The radiologist really did not feel comfortable (or was lazy) in his/her interpretation of the images. I would call him and request a comment on the fusion status. The “soft tissue intensity” is really “soft tissue density” and this is smaller than before which is good.

Why you would have RFAs (radio frequency ablations) at L4-5 is a mystery as this level should have been fused and an RFA here would have been less than worthless.

Is the leg pain the same side as the “density”? Does it seem to follow the L5 or S1 nerves as these would be affected by the “density” at L5-S1. See https://neckandback.com/conditions/symptoms-of-lumbar-nerve-injuries/ to see what nerve could be involved.

As I noted before, L3-4 could become an issue or already is an issue now. If you would need surgery for this level, I would strongly advise the use of BMP (bone morphogenic protein) and only a posterior surgery (TLIF) if you need future surgery.

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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