L5 S1 herniation with 2 extrusions after L2 thru L5 fusion

Tagged: 4 level fusion

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dog mom
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May 2, 2017 at 7:13 pm

Post count: 1

#24721

Hello Dr Corenman, I am astounded to find your forums online, including your diligence in responding with complete and helpful information. You are an angel for those of us suffering out here with debilitating pain.
My question is about what I can expect for my future. I am a 60 year old female with Psoriatic Arthritis that was diagnosed 40 years ago. I’m sure you know, but my understanding is that PsA, unlike RA, frequently attacks the spine. In my case, when I was younger I was very athletic. I was a diamond skier, cycled, sailed etc. In other words, my spine took a pounding.
In February 2016, I had a triple fusion of L2 through L5 because of collapsed discs and lots of other related issues. On December 22, 2016, I herniated the L5 S1 disc by sitting with my legs crossed, and a bit crooked to hold my computer on my lap, for about 2 hours. I was bedridden, laying exclusively on my left side with pillow positioning, for about 6weeks as there were multiple complications to finally getting a diagnosis. I had surgery on March 28 of this year to fix the herniation. When my surgeon got in there, there were two extrusions from the disc, which I understand is quite unusual. (That explained the extent and severity of my pain for 3 months.) One extrusion was easily cleaned up, and relieved the pain that was horizontal across my butt. The other extrusion was attached to the nerve derma and caused a tear in the derma when removed. My surgeon used superglue to close the leak (2 drops of spinal fluid).
My recovery has been slow but steady, with the same hip, leg and ankle pain as prior to surgery, but it feels different, indicating something was done in the same irritated location. My understanding is that I just need to be patient to let that nerve and derma heal. I started aqua PT two weeks ago with good results. Then last Friday night, I slept on my right side for a few hours. Finally the nerve pain woke me up, and I went back to my usual left side. However, since then I have had significantly increasing pain comparable to what I was experiencing prior to surgery. I am now as disabled as I was prior to surgery, if not even more.
From my analysis of my pain and what I have researched, I may have just badly irritated the nerve, which can be calmed down with oral steroids for a bit. Or, I may have somehow re-herniated the disc with activity prior to or subsequent to the event while sleeping. I have an appointment with my surgeon in 2 days, which may answer some of my questions, but I am hoping you can help me with the bigger picture prognosis.
If this is another herniation, am I looking at possible fusion of the L5 S1 in the near future? If I end up with L2 thru S1 fused, what impact will that have on my functioning? I’ve heard that this can cause lots of problems with continence. I’m also wondering if sex will ever again be in the picture.
Your advice would be greatly appreciated.
Thanks, Susan

Donald Corenman, MD, DC
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May 5, 2017 at 4:50 am

Post count: 8660

#24728

The L5-S1 level herniating after a three level fusion at L2-5 is not uncommon. This disc has to take the load of the fused levels above and if not in perfect shape (prior degeneration), can tear thru and thru and then herniate. The tear that occurred in the dura can complicate recovery depending on how severe the tear was and how well the repair went. Since now you have “significantly increasing pain comparable to what I was experiencing prior to surgery”, I believe this calls for a new MRI with Gadolinium.

I would say that you are looking at a fusion of L5-S1 as a disc herniation in the only lower level left in the lumbar spine normally will make the disc be incompetent enough that a fusion is needed to stabilize the level. This should actually make you feel better, not worse as long as you don’t want to take up triathlons or power squat weight lifting. There should be no issues with continence or sex.

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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