L5-S1 Herniation: Is it time for surgery?

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Rkrebs
Member

January 9, 2013 at 6:50 pm

Post count: 3

#7700

I have been dealing with debilitating back pain/radiating leg pain for 7 months now. As many here, I’ve been unable to work, have dropped out of school, and have grown apart from many people close to me. My MRI has shown a 4mm right para central disc protrusion barely abutting the S1 nerve root. I have had one epidural that provided no relief and am scheduled to get my second one in a week. I have also recently been diagnosed with femoral acetabelar impingement and possibly labral tears in my right hip pending an MRI. I have previously had weakness in my calf that has since gone away. However, despite putting in a ton of time doing core stabilization/swimming I cannot shake the pain in my back and butt as well as the dull ache that remains in my leg.

Questions:

At this point, even if the epidural works, what are the chances that the disc will actually heal on its own? I have been extremely diligent with my PT and have seen no results as of yet. I was in my first year of dental school before I had to take the year of to take care of my health and don’t want this to be a recurring problem if possible.

How does the diagnoses of FAI and probable labral tears play into my pain? Is it possible the dull ache in my leg is coming from that?

I also get occasional tingling and numbness in my right foot. Is this a sign of nerve damage and is it something that may eventually go away?

I also, since around 4 months ago have broken out in hives and despite any antibiotics I take can not seem to get rid of them. On top of that I wake up some mornings with purple bruises running down both legs, and sometimes little ones on my arm. I have no idea how I get this as they always only show up after I sleep. Do these symptoms maybe fight into some of the puzzle too?

I’ve seen a good many physicians at this point and am running out of options here as I will have to inform my dental school soon if I will be able to return next year. I appreciate that you take the time to respond to all of these comments and I look forward to hearing back! Thank you!

-Rob K

Donald Corenman, MD, DC
Moderator

January 14, 2013 at 2:50 am

Post count: 8660

#7730

Disc “healing” is relative. The annulus of the disc (outside of the jelly donut) is avascular (no blood supply) and tears in this wall will not heal. The disc hernation material is the inside jelly (nucleus) and will not “heal”. This material however will shrink down over time and the nerve can adapt to the new compression. This is how an individual “recovers” from a disc herniation.

Your FAI (femoral acetabular impingement) can occasionally mimic disc hernation pain. The best way to differentially diagnose this pain generation is with a selective nerve root block of the herniation level and then a diagnostic block of the hip joint. The hip pain will not get better if the nerve compression is not causing this hip pain. A hip block will however yield relief if this impingement is causing the pain.

Hives and purple bruises (purpura) do not relate to the hip or the spine problems. You do need to see your primary care doctor for work-up of these sooner than later however.

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.

Rkrebs
Member

January 14, 2013 at 7:15 am

Post count: 3

#7735

Thanks for the response Dr. Corenman. I will be going for my second epidural injection soon which will hit the s1 nerve root, which is what the disc is impinging upon. Is this the same as the nerve root block you were suggesting?

I will soon be getting an MRI of my hip and the closer I get to figuring it out I am starting to think that FAI could be the major source of pain for this. If that is the case I will likely see Dr. Phillipon in your clinic when I can make an appointment. Once again, thanks for the reply.

Rkrebs
Member

January 31, 2013 at 2:25 pm

Post count: 3

#7868

Hello again,

I have just undergone the nerve root block procedure at s1 which has given me minimal relief. I have no pain at the injection site in the low back, however, the pain in the back and side of my thigh as well as the the very cold feeling in my foot has persisted. I have had this problem for over 8 months now and have not seen much success from PT, and about 25-30% pain relief from the nerve root block. I unfortunately had to decline my return to graduate school as I am still incapable of focusing very well while sitting due to the pain. I understand it’s hard to tell without the MRI, but if I get surgery what are generally the chances of reherniation in the future say 5, 10, or 20 years? It is about a 4mm right paracentral disc protrusion. I am at my wits’ end with this and am ready to move on with my life. Any advice or help would be appreciated. Thanks again.

Donald Corenman, MD, DC
Moderator

January 31, 2013 at 7:58 pm

Post count: 8660

#7869

The first three hours after the nerve block is the critical time to determine if you gained relief. I will assume that you only improved 25% in that period of time. If that is the case, then a hip block would be the next test. If the temporary improvement in the first three hours would be around 80%, the pain generator is the hip.

If the hip pain only becomes 25% better, then there is a dilemma in diagnosis as the blocks did not point to the correct diagnosis. The physical examination tests would have to be relied upon to decide which disorder causes more pain. If that series of test does not point to the painful structure, you might have to undergo both surgeries to gain 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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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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