L4-L5 microdiscectomy to TLIF after first reherniation?

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elijah.walters
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November 4, 2014 at 2:56 am

Post count: 4

#11644

Hello, I had a L4-L5 microdiscectomy in July of 2013 to treat a herniated disc causing sciatic nerve pain down my right leg, I recently had nerve pain down the right leg again after being pain free since surgery and an mri/ct scan showed a slight reherniation at the same level and a fracture of the spinous process at L4-L5. I was told that it is time for a TLIF becuase the fracture shows instability at that level, the problem is I am a 22 yo male college competitive cheerleader on scholarship and also a junior pre-med student. I was wondering if you think a fusion is the best option here or if a 2nd microdiscectomy with some physical therapy could return me to sports and provide minimal sciatic symptoms to avoid the major fusion surgery? Thank you for taking the time to read this.

Donald Corenman, MD, DC
Moderator

November 4, 2014 at 5:36 am

Post count: 8660

#11646

I am confused as a spinous process fracture (which is rare in itself) does not by itself connotate instability. A one-time recurrent herniation at L4-5 generally calls for a repeat microdisectomy.

How old is the spinous process fracture? Did it occur due to some impact activity (cheerleading) or did it occur to iatrogenic results (the spinous process fracture occurred due to thinning of the lamina with the previous operation-rare)?

Do you have flexion/extension X-rays and if so, is there instability noted? Do you have foraminal stenosis (see website) as the cause of your leg pain?

Many questions to answer.

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.

elijah.walters
Member

November 4, 2014 at 6:29 am

Post count: 4

#11648

I apologize for that, it is actually a right side transverse process fracture. It is not known how old the fracture is, the sciatica pain just re-developed within the last three weeks and there was no acute injury that I know of, the sciatica was a gradual onset over a week and I have very little back pain. There is no evidence of foraminal stenosis on the mri, just a small disc fragment pressing on the nerve at the site of the previous surgery. I had a ct scan done today that shows the transverse process break, no flexion/extension x-rays were taken and the doc said that since there is a fracture at the level of my previous surgery that leads him to believe there is instability and fusion is the best option as opposed to a second microdiscectomy which he says will bring me right back in. I don’t disagree with what he says, I just believe it is a little aggressive being that I am only 22 years old.

Donald Corenman, MD, DC
Moderator

November 4, 2014 at 9:20 am

Post count: 8660

#11649

Transverse process fractures are not dangerous or an indication of instability. Most when broken will not heal with bone. They heal with fibrous tissue and the apparent fracture line stays forever. This has nothing to do with instability and everything to do with an avulsion fracture (the psoas muscle will pull off this transverse process with a strong contraction) or an impact that breaks off this bony structure.

Personally, if you need surgery and based upon what you have told me, I think a simple redo microdisectomy would be the appropriate treatment. That is, unless there is substantial evidence of instability.

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.

elijah.walters
Member

November 5, 2014 at 4:48 pm

Post count: 4

#11661

Thank you very much for your input this was extremely helpful. I am seeking a second opinion from my pain management specialist where I will do a felxion/extension xray to rule out instability. In this case I will then contact a new surgeon to perform a second microdiscectomy. He had said something about lumbar nerve ablation, do you believe this is an option in the case being that the sciatica goes all the way down my leg? Also, if a second surgery is done do you think returning to competitive cheerleading (primarily lifting people above my head) would increase a chance of another reherniation? I have been told there is no evidence that this would be the case, however I am sceptical. I do avoid any bending while competing but I am on scholarship so it would be great to continue but only if it will not hinder my recovery. I am a junior pre-med student and want to do everything I can to avoid chance of a fusion during medical school.

Donald Corenman, MD, DC
Moderator

November 5, 2014 at 8:18 pm

Post count: 8660

#11662

Lumbar nerve ablation is a procedure to ablate the nerve that enters the facet. This procedure is performed for facet mediated pain which according to your complaints is not what is causing your pain.

You can return to competitive cheerleading with a somewhat higher risk of recurrent herniation. The most common position for recurrent herniation is “BLT” (bending and lifting when twisting) and this would be the position that you would be in when you “catch” the propelled mid-air individual.

If you want to avoid a fusion, I would unfortunately not participate in cheerleading.

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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