L5 Isthmic Spondy & Transitional L6 Segment

Tagged: Isthmic Spondylolithesis

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10sAlex
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September 13, 2016 at 9:14 pm

Post count: 6

#22972

Dr. Corenman,

First, I thank you for the work you do as a doctor and with this website. I am sure you have done more good in the world than you’ll ever truly know.

I will give you some factual and brief background and then ask my question regarding surgery…

I am a 34 year old male in excellent shape. I am probably in better shape now than in my 20’s. I was a very athletic kid, competed in several sports and eventually settled on tennis. I competed collegiately in tennis at a high level. Have no recollection of back pain my entire life except for one acute incident when I went snowboarding when I was 18. Woke up the next morning with back pain and never went again in my life.

I currently work as a physical education teacher and tennis coach. 6 months ago I began having nerve pain down my right leg. Specifically the pain is along the L5 nerve root, buttocks, outer thigh, outer shin, top of foot and big toe. My big toe is numb most of the time I am vertical and the pain builds gradually and is relieved completely when I flex or sit. Went to the doctor and found out I have isthmic spondylolithesis at L5/S1. My S1 is a transitional segment where it looks more like an L6, it is described as partial lumbarization. There is a rudimentary disk between S1 and S2. I am not sure if there is movement at that level. My spondy is a grade I or II, the slip is about 25% anteriorly. Flexion/extension X-rays show it is stable. My MRI is completely normal from L4 disk up with no signs on degeneration. L5 is anterolisthesis due to bi-lateral pars fracture. L5 has diffuse disk uncovering and bilateral facet arthritis, central left/paracentral annular fissure, mild recess narrowing present bilaterally but more so on the left. Finally, significant neuroforaminal narrowing is present bi-laterally.

So in the past 6 months I have done the course of PT and still workout daily, have been seen by a movement specialist to see if any deficiencies are feeding into my spondy and there are not, have taken a course of oral steroids and have had 2 injections. One injection was an epidural steroid and the second was transforaminal and specific right to the exiting L5 nerve root. None of this has helped, in fact it has only progressed with time. I can walk about 20 minutes before I have to sit down and flex. As you can imagine this is significantly hampering my ability to work, especially on the tennis court.

I have seen several doctors and it seems as through I am approaching a surgical intervention. One doctors recommends decompression and posterolateral fusion, another an ALIF without posterior hardware. another an ALIF with pre-cutaneous posterior hardware and another a TLIF. The posterolateral with bone from my hip seems old fashioned and safe. The ALIF without posterior hardware doesn’t make any sense to me because I don’t think it will hold up. The ALIF with posterior hardware makes sense because I get reduction of my spondy but I worry about decompression because it is indirect and my fragment is still floating around back there. And the TLIF makes the most sense because I get the inter body fusion, removal of the fragment and guaranteed visualization that my nerves are decompressed. However, the doctors says he would fuse me in place during the TLIF because it is hard to reduce posteriorly with the screws and it increases the chances of nerve damage.

So my questions are what surgery would you recommend? How will my transitional segment play into this? And can you enlighten me on the benefits/drawbacks of reducing my slip? It makes sense that the ALIF will give me the best reduction as it is necessary for decompression and the doctors rational is to reduce my chances of ASD. The fusion in situ with the TLIF also makes sense especially since my body is used to it being there for a long time but I worry about increasing my risks ASD with it fused out of alignment.

Can you give me a little guidance. I would also be interested in your consulting services.

Donald Corenman, MD, DC
Moderator

September 14, 2016 at 5:03 am

Post count: 8660

#22977

It does appear that your isthmic spondylolisthesis needs to be repaired surgically. Your transitional segment is probably stable unless there is a full separation between S1 and S2 (very unlikely). Many times, the X-ray is obvious in that there is a large transverse-alar articulation which generally means this transitional level is stable. See Bertolotti’s syndrome on this website. If there is any question, a CT scan can settle this question.

I almost always use a TLIf for these cases. It allows the nerves to be fully decompressed, allows both an anterior and a posterior fusion through only a posterior approach, allows great fixation through instrumentation and there is no need for bone graft as the broken lamina should be removed and acts as a wonderful bone graft. I like that the TLIF surgeon does not want to reduce the slip. Generally, any reduction can stretch the L5 nerve roots and cause some injury.

Just a posterolateral fusion without the TLIF is not enough fusion mass and has a high pseudoarthrosis rate. The ALIF without posterior fixation has a higher pseudoarthrosis rate and even the ALIF with posterior fixation has a higher chance of residual nerve pain.

The ALIF will not reduce your chances for ASD (adjacent segment disease).

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.

10sAlex
Participant

September 14, 2016 at 6:19 am

Post count: 6

#22989

Dr. Corenman,

I thank you for your response and feedback. I have done my research and fortunately have an understanding of anatomy and biomechanics to understand this stuff. You have confirmed my logic as well.

I did have a CT scan done and I just looked at the imaging myself and yes there are transverse alar articulations on both sides connecting the transitional segment to my sacrum, so is it safe to assume that is stable?

In doing the TLIF procedure should there be bone graft placed in the inter-body fusion and the lateral gutters or just the inter-body space?

I would like to have one more appointment with the TLIF surgeon and really understand how he will perform surgery and want to check to make sure he uses inter operative neuro monitoring, O-arm to place screws, etc. Anything else I should ask for specifically?

After that I think I would like to send you all my testing and imaging (X-Rays, CT, MRI, and EMG) and use your service to discuss. Unfortunately I am in Pennsylvania so having things done in Colorado may not be very feasible. Fortunately I live near a major city with multiple doctors.

Donald Corenman, MD, DC
Moderator

September 15, 2016 at 6:44 am

Post count: 8660

#22995

I think your transitional segment is most likely stable and does not need to be addressed surgically. The TLIF should also include a posterolateral fusion as there are times that this area will fuse first and destress the anterior fusion.

The gentleman seems to be a sound surgeon and if he has good hands, you should do well.

You can call my office if you want to use my long-distance consultation services.

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.

10sAlex
Participant

September 23, 2016 at 6:08 am

Post count: 6

#23054

Dr. Corenman,

I thank you for your feedback and will give the office a call when ready.

10sAlex
Participant

October 13, 2016 at 6:15 am

Post count: 6

#23196

Dr. Corenman,

Have another appointment I am waiting on… but I do have one last question regarding the inter body spacer. I have done some research and found that there are basically 3 different varieties PEEK, PEEK coated in Titanium and all Titanium. It appears that perhaps the all titanium spacers such as those from Titan Spine (http://www.titanspine.com) have the best results of fusion which is why they started coating PEEK in titanium. Do you have any recommendation or know anything about spacers or am I just being to concerned as they all fuse very well. Just want to make sure I due my research and due diligence as I am 34 and have to have my back the rest of my life.

Best,
Alex
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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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