[Renee123]

#21317

1.) Can you please explain this last part to me “BMP has a learning curve and if used properly, will not generally overgrow if used in the disc space.” What kind of learning curve ?

It would seem to me that very small dose of BMP should be included in the disc space, where is the danger ? MY surgeon only wants to use BMP on the sides.

2.) Could I wind up with a later fusion and not a fusion in the disc space, like sperry guy ?

3.) Also, what are you thoughts on ALIF with posterior mini open pedicle screws and leaving the pars fracture in. Is this acceptable to you ? It doesn’t matter if I fuse ALIF or TLIF, once you fuse you win, right ?

Getting ready to schedule and wish I lived closer to you.

[Donald Corenman, MD, DC]

#21319

The use of BMP can be made less problematic by using the correct dosage (in my opinion, 1.5-2mg in the disc space), protecting the canal from disc space overflow (no significant bleeders in the disc space) and using “blocking” agents to prevent the eluding of the BMP into the canal. This with prevention of perforating the disc endplate cortical bone (which can lead to osteolysis) will make using BMP in the disc space relatively safe.

Using BMP on the sides is an excellent plan as this substance almost never fails to create a fusion in the “lateral gutters”.

You can have a posterolateral fusion without an intradiscal fusion but in my experience, if you do get a solid posterolateral fusion, almost always will the intradiscal fusion heal solidly.

I think an ALIF with posterolateral screws doesn’t make sense to me. I will not argue with the technique as it can be effective but if you are going in the back anyway, why not skip the anterior approach? You are already making an incision to expose the back of the spine, why not decompress the roots and create an interbody fusion from the rear and leave the abdominal wall alone?

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.

[Renee123]

#21341

Dr. Corenman, you are a great surgeon and you have a great way of communicating with people. This is hard to find with other surgeons. Thank you !

To answer your question, the theory behind having an ALIF with minimal invasive “perc screws” is to avoid a midline incision of 4-8 inches on the back and also to avoid muscle stripping and scar tissue. Many surgeons have suggested leaving the pars fracture in place to avoid muscle and nerve disruption thereby only using the mini-open perc screws. I have no current leg pain or numbness so this surgery was suggested many times as it is suppose to have a faster less painful recovery.

Keep in mind that most spine surgeons are not as skillful as yourself, it is an easier surgery to go through the abdomen and probably more expensive as well. Many surgeons make the argument that placing a cage through the front with BMP will heal faster and give better support with more bone fusion.

However, there are a couple very experienced surgeons that have told me the pars fractures needs to be removed even if I am not having leg pain. As mentioned, one suggested TLIf leaving half of the pars fracture in, which makes no sense.

1.) What are you thoughts on this ? I read about the bone spurs, but again there are no leg symptoms.

2.) Also, what are you thoughts on Sperryguy. How could he have a posterolateral fusion without fusion in the disc space ? Seems impossible.

Thank you again !

[Donald Corenman, MD, DC]

#21342

You have to ask yourself why you support the anterior approach and why you have the understanding of the posterior approach you discuss.

The anterior approach is not benign. You have to cut through the muscular wall of the abdomen. This de-innervates some of these muscles and makes them non-functional. Have you seen an abdominal hernia that occurs from this approach? I have. The intestines have to be mobilized and retracted-possibly creating injury and the possibility of bowel obstruction later if adhesions form post-operatively. I have occasionally seen ureter injuries (when at the university) and don’t forget the great vessels have to be mobilized. I have seen injury to the common iliac veins (veins generally have a very thin wall) and adhesions to these vessels make a repeat approach very risky. The sympathetic chain lies to the side of each vertebra and it is common to see a warm leg (the side the sympathetic chain is injured) as the cold leg actually is the side with intact sympathetics. Add to that, there is no iliac bone graft can be taken unless you make another incision along the crest to take graft. Retrograde ejaculation is estimated to occur in 4% of males with an anterior approach. Many of these problems can be mitigated with a general surgeon who approaches the spine but are not eliminated.

Let’s then look at the posterior approach. You note an incision of 4-8 inches. I assume there still are individuals who use that technique (and I was trained with that technique 25 years ago) but techniques progress and my current incision in a moderately muscular individual is about 2 inches.

Muscle stripping is important at the level of the fusion (multifidi and rotators) as you want to encourage fusion between the facets and transverse processes (or the TPs and ala of the sacrum). These muscles that connect from segment to segment are not going to be used as these two segments will become one (which is the purpose of the fusion in the first place). By placing pedicle screws-even with the “minimally invasive technique”, you have to strip the insertion of the multifidi to gain access to the pedicle screw site.

You have a non-functional lamina in an isthmic spondylolisthesis due to the pars fractures. Why not use this bone as bone graft? During this laminar removal, why not decompress the L5 roots (which half the time are compressed due to a pedicle spur that grows due to the pars fractures). Finally, since you are already there, simply retract the S1 root like you would do in a microdiscectomy and perform a TLIF (with the bone you have from the laminar removal).

Again, I have no objection to the ALIF but think it is too much surgery where better results can occur from a TLIF.

I have seen non-fusion in the disc space both after a TLIF and ALIF with a solid posterolateral fusion but it is very rare.

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.

[Renee123]

#21359

Thank you very much, that about sums it up !

I am told at L5,S1 there would be a horizontal incision and the vascular surgeon would be going underneath the bowels to the spine, not retracting them. The incision is in the pelvic area would be approximately 6 inches. I agree that there seems to be no point in taking the risk if TLIF can be done. However, as a female, I think many Dr’s believe there is less risk than a male.

Having a 4-6 inch incision down the middle of the back doesn’t sound like much fun either. I guess it depends on how the surgeon was trained.

I am in full agreement with you, I don’t see how tunneling through abdomen can cause absolutely no adverse effects. I was unaware of adhenions that can form around the arteries !

[Donald Corenman, MD, DC]

#21360

If the approach surgeon is good and the spine surgeon has good experience, you should do just fine.

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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