L5-S1 Fusion Hardware Removal

Tagged: removal

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steve4andrea
Member

September 20, 2013 at 10:21 am

Post count: 3

#9423

Hello Dr. Corenman,

Thank you for your time you devote to this forum, it is a truly unique situation.

I am inquiring about your opinion regarding the removal of fusion hardware after the vertebrae have fused. I read the story of your patient Liz who unfortunately had numerous fusions and in every case you indicated that you later removed the hardware with another surgery.

My wife had an L5/S1 fusion in Feb. 2009 and we suspect that the hardware is creating complications for her. What is your protocol for removing hardware?

Steve

Donald Corenman, MD, DC
Moderator

September 22, 2013 at 10:54 pm

Post count: 8660

#9432

I remove hardware after fusion in about one of every forty patients. Most of the time there is no need to remove the metal and this avoids another surgery.

The reasons for removal are varied. Some patients are very thin and the hardware does take up some space. Removal affords relief. Some patients have barometric pressure sensitivity and removal eliminate this symptom.

The other reason is one of varied degrees of stiffness. The titanium used in surgery has a certain amount of bend (called modulus of elasticity). The fusion bone also has a certain amount of flexibility. The difference in the two modulus of elasticities can rarely cause discomfort at the bone metal interface and removal of the metal eliminates this difference.

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.

steve4andrea
Member

September 23, 2013 at 3:22 am

Post count: 3

#9444

Let me give a little background, my wife had an orthoscopic L5-S1 laminotomy in Aug 2008 that lead to a pseudomeningocele, then an orthoscopic exploration in Nov 2008 that showed a herniated nerve root in a dura tear and finally an L5-S1 fusion with a stitched dura repair in Feb 2009. All of this lead to problems with pre-existing Tarlov cysts for which she had 2 procedures (AFGI) at Johns Hopkins. She was left with a lot of residual pain, most of which has subsided, but-

She was never a large person (5’3″, 120 lbs.) before the surgeries but since then she has lost weight (at her lowest she shrunk to 93 lbs. and is currently 103 lbs.) and is bothered by pain (burning and aching) and sensitivity to touch or pressure in the surgical/hardware area when she tries to return to an active life. A follow up CT in 2010 showed no problems with the fusion and no reason for the lingering pain- we’re wondering if removing the hardware would be a reasonable request. I have read of challenge testing with lidocaine injections, what is your opinion of this?

Steve

Donald Corenman, MD, DC
Moderator

September 23, 2013 at 7:49 am

Post count: 8660

#9447

Your wife had a stormy operative course. Hypersensitivity at the incision is not typical for hardware irritation but is typical for nerve injury. However taking out the instrumentation is a relatively easy surgery and may be helpful.

You mention AFGI for Tarlov cysts. I am unfamiliar with those initials. What procedure did she have performed for these cysts?

The lidocaine “challenge” test is designed to infiltrate the hardware/bone interface with numbing medication to see if the hardware is irritating the bone. The problem with this test is that the lidocaine rarely behaves the way we want it to and may not find its way along the bone. Also, other structures next to the hardware can also be numbed which gives a false positive (a test which indicates relief when the actual surgery will not provide 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.

steve4andrea
Member

September 23, 2013 at 10:37 am

Post count: 3

#9454

Yes, it has been an interesting five years and as is often the case the story behind the story is even more interesting but it is long, complicated and slanderous to some involved and this is not the place to tell that story.

The AFGI stands for Aspiration w/Fibrin Glue Injection and is done by an Interventional Radiologist (Andrea’s was done by Dr. Kathuria at Johns Hopkins) and was developed by Dr. Donlin Long and a description can be found at his website (he’s listed in Google) under Clinical Practice / For Tarlov Cyst Patients. Andrea was/is one of the successes, her extreme tailbone pain during valsalva type events is gone.

I am heartened to hear your opinion regarding the challenge testing, we have experience with diagnostic injections and are familiar with the “general area” nature of the results and were concerned about the validity (both positive and negative) of this test.

We will move forward with having Andrea’s hardware removed, I’ll let you know how it turns out. Again thanks for your time on this.

Steve

Donald Corenman, MD, DC
Moderator

September 25, 2013 at 10:32 am

Post count: 8660

#9466

The AFGI treatment is interesting as fibrin glue is a product that when applied to raw nerve roots will cause adhesions. These Tarlov cysts are enlargements of the dural sac in the sacrum (generally). These cysts encase the nerve roots. Injection of the fibrin glue into these cysts would have to come in contact with the nerve roots. I will have to contact Dr. Long to gain a better perspective of this treatment.

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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