L5/S1 Lateral Recess Stenosis

Tagged: lumbar lateral recess stenosis missed after microdiscectomy

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Donald Corenman, MD, DC
Moderator

December 29, 2018 at 2:53 pm

Post count: 8660

#29938

Drains are important in every case. Fat grafts can scar or create new onset root compression if displaced so have not been used in some years. Local steroids should be used in almost
every case of surgery for radiculopathy.

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.

YNA
Participant

December 30, 2018 at 9:28 pm

Post count: 15

#29950

Dr. Corenman, thank you again for this forum for all of us and answering our questions!

When I look up “lateral recess decompression” I see that the endoscopic and percutaneous (through the tubes) minimally invasive surgeries all claim they can decompress the lateral recess. Why then did it not work for me? My surgery was through the 16mm tube and included a microdiscectomy, laminoforaminotomy, and medial facetectomy. Is it just limited by the small tube exposure (even though they say they can move it around and do a bilateral decompression)? Or was it because my end plate is protruding out more than normal?

If I didn’t have a prior surgery, would I have had other minimally option these have been good options?

Thank you again! I’m sorry, I have so many questions.

Donald Corenman, MD, DC
Moderator

December 31, 2018 at 12:10 pm

Post count: 8660

#29952

A lateral recess decompression can be performed through a tube (typically a Metrx tube) reasonably well but probably not performed endoscopically very well. If the procedure is performed for nerve root compression (typically a herniated disc) and there is no thought about lateral recess stenosis (as you have to take off more facet than you anticipate), the LRS may not be adequately addressed surgically.

Don’t get stuck on the term “minimally invasive” which is a real common dilemma as the term is “sexy” but these procedures are just as invasive as a microdiscectomy but have a similar or lower success rate.

Remember that you would still need diagnostic blocks to prove the presence of LRS.

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.

YNA
Participant

January 1, 2019 at 9:30 am

Post count: 15

#29955

Dr. Corenman,

I was wondering what your thoughts were in regards to these symptoms:

When I flex my knees, my feet (inside, no specific distribution, but not dorsum) feel more numb or more crampy. Is this just from the fact the tibial nerve already under stress cannot tolerate further compression with knee flexion? When I sit or lay down, I have to make sure I don’t flex my knees too much or both feet will develop paresthesias and numbness.

Also, 4/5 weeks after my original MIS, when I started to spasm, cramp, and have difficulty walking due to spasms and pain in my lower extremities (hamstrings, gastrocs, and quads!- L5), I was very hyperreflexic in my lower extremities when I was examined. Two months later, my reflexes are normal. What do you think occurred?

Happy New Year and thank you, again!

Donald Corenman, MD, DC
Moderator

January 1, 2019 at 11:46 am

Post count: 8660

#29956

Normally, the tibial nerve is more relaxed with knee flexion (remember that a tension sign for the sciatic nerve is hip flexed, knee extended or a positive straight leg raise test). This is another reason for the selective nerve root blocks to determine if the sciatica is generated by the L5-S1 level or this possibly could be a peripheral neuropathy.

Hyperreflexia should not be a part of your lower motor reflex signs. Compression of a peripheral nerve will cause either no change or diminishment of a reflex.

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.

YNA
Participant

January 3, 2019 at 7:00 pm

Post count: 15

#29967

Dr. Corenman,

Two weeks ago, I had seen a spine surgeon (professional sport team doctor) and he recommended a decompression. We didn’t talk further, as he made it sound so simple — outpatient, 1 hour, simple!

More recently, I saw another well-respected (was told the “best” by another spine surgeon) orthopedic spine surgeon who recommended an L4/5 AND L5/S1 decompression, but he did not want to say whether I would truly have relief or not. He almost said to me to live with the symptoms if I can unless it was affecting my quality of life. I was so disheartened by the fact that a decompression may not offer any relief!

Two weeks ago, I had started Gabapentin with some relief, but then started ramping my standing/walking activities only to experience that cramping and aching. I don’t feel very confident and hopeful from what he said that surgery would help me. He also said he wouldn’t recommend either a SNRB or a CT. He said if the outcome of the SNRB doesn’t support the diagnosis of lateral recess stenosis, it isn’t helpful. It may not be predictive of the outcome of surgery. He also felt the CT scan wouldn’t add anything because it was clear to him at the L5/S1 level my DRG was being compressed. I have worked with him in the past and I (as well as the other doctors hold him in high regard). He also said he doesn’t put a drain. Is it because of the use of bipolar cautery? I was curious what your thoughts are. I feel like I am between a rock and a hard place. Thank you!
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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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