L4-L5 Foraminotomy post fusion?

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jbfd
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June 6, 2013 at 5:38 am

Post count: 2

#8812

I had back surgery done in March 2006 for problems of spondylolithesis causing sciatica and hamstrings spasms to both legs. Surgery consisted of laminectomy, decompression and discetomy with instrumentation fusion of pedicle screws.It was done by an orthopedic surgeon and neurosurgeon.

I had immediate relief of the sciatica and no longer had spasms of the hamstrings. I had very little post-operative pain and used Dilaudid only at night to get a good night’s sleep.

Immediately after the surgery,I felt a new problem. There was an unusual amount of tightness and spasm to the dorsolateral left thigh. It would worsen during the day but went away during the night. I was able to walk for longer & longer distances without pain, but the left thigh would go into tightness, spasm and pain when I stopped walking. Sitting for long periods of time made it worse.

My doctor thought I was having problems with scar tissue in the foraminal area of the fusion. In 2008, a fluroscopic guided steroid injection was done to L4-L5. It didn’t have any effect at all.

Since then, my left leg problem has worsened and I now have persistent burning pain to both feet. A physiotherapist determined I have very weak hip abductor strength, left side worse than right. I have tried various exercises to strengthen the hip muscles, but they continue to feel fatigued and weak. I have consequently developed a lot of lateral knee pain.

I had an MRI done in April 2013. The report indicates :

Pedicle screws transfix L4 and L5.

L2-3: No disc bulge or herniation exiting nerve roots appear normal.

L3-4: There is Mild disc bulge but no focal herniation. Moderate narrowing of the exiting neural foramina bilaterally.

L4-5: There is disc space narrowing with anterolisthesis of L4 on L5. Secondary to this there is mild narrowing of the right neural foramina and moderate narrowing of the left neural foramina.

L5-S1: There is mild disc bulge but no focal herniation. There is mild narrowing the exiting neural foramina bilaterally.

Impression: No recurrent disc herniation is present. No enhancing scar tissue is noted.

Would you be interested in looking at my MRI and seeing why I am getting the unusual left leg pain?

I am happy to say that I don’t have any pain in the low back. I can lift and carry heavy weights with no problems or immediate increased pain to the left thigh.

My doctor says I have foraminal encroachment and wants me to have another fluroscopic injection. I wonder if the first injection wasn’t into the foramina?

Can a foraminotomy be done in L4-L5 if there is already hardware from the fusion?

Donald Corenman, MD, DC
Moderator

June 6, 2013 at 7:24 pm

Post count: 8660

#8813

By interpretation of your films and history, you had a degenerative spondylolisthesis of L4-5 with spinal stenosis. You underwent a typical posterolateral fusion with a central decompression of that level with what sounds to be very reasonable results.

“Tightness and spasm” of the dorsolateral thigh can have many potential origins. Of course one could be nerve root irritation and the fact that this new symptom occurred immediately after your surgery leads to the suspicion that it could be from nerve compression after surgery.

You underwent an epidural steroid or foraminal steroid injection in 2008 without any relief. The most important time to record relief after the injection would be the first three hours (when the anesthetic is working). If you remember back to the first three hours and no relief was afforded you in this time period (assuming the injection was placed in the correct location), then your pain is not from the nerve root injected.

Burning pain that is bilaterally equal is more concerning for peripheral neuropathy. See website for description of that disorder.

“Tightness and spasm” of the dorsolateral thigh could also originate from hip disorders. I assume you have had a pelvis X-ray. If not, that would be the next step. Trochanteric bursitis could also cause these symptoms. Deep palpation of this region could reveal the presence of this disorder and a simple in-office injection could resolve it.

Yes-a foraminotomy could still be performed after a fusion of this level. I would be happy to review your films. Please call the 888 888-5310 number.

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.

jbfd
Member

June 6, 2013 at 10:07 pm

Post count: 2

#8814

Thank-you Dr. Corenman. I’ll try and make arrangements for you to view my films. Yes I have had hip xrays with no apparent findings of anything wrong.

Ironically, the hospital called me yesterday and they have fitted me in for a foraminal injection today. It had been ordered by my family doctor last month.

I’ll take note of whether I get any immediate relief from the injection. The radiologist doing the injection will be be able to see from the 2008 film, where the previous injection was done. Maybe a slightly different location will be tried this time.

It might be too late for you to respond, but what steroid and/or anesthetic do you recommend and what is the appropriate dosage?

I live in a small community and I met the orthopedic surgeon at the schoolyard last night while waiting to pick up our children. When I told him that I would be having an injection today, he was surprised that it has so long ago ( 5 yrs ) from the last injection. He is adamant that my problem is due to scar tissue and that a foraminotomy would likely only cause further scarring and damage.

Donald Corenman, MD, DC
Moderator

June 7, 2013 at 9:21 pm

Post count: 8660

#8822

Your surgeon could be correct that this is scar tissue causing root compression but that is not very common. Again, with your symptoms being bilaterally symmetrical with burning to both feet, peripheral neuropathy can also be a diagnosis. See the new section on peripheral neuropathy on this website.

The foraminal stenosis could be causing your symptoms. Again, keep a pain diary to determine if that nerve root is the cause of your pain. See the section on pain diary to understand how to record the results. A successful injection (three hours of temporary pain relief) will identify the root involved.

This temporary relief does not mean however that the nerve compression is absolutely causing the root dysfunction. If the root has previous injury from the original herniation (see section on nerve root recovery and chronic radiculopathy), surgical manipulation or even scar tissue (rare), this injection will yield relief.

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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