L5/S1 Lateral Recess Stenosis

Tagged: lumbar lateral recess stenosis missed after microdiscectomy

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Donald Corenman, MD, DC
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January 3, 2019 at 9:42 pm

Post count: 8660

#29968

I understand your confusion with all these different and disparate conclusions.

I am unclear why two levels would be necessary to include in an operation. It is possible that a decompression would not yield relief but that would be unusual if your selective nerve root blocks were diagnostic. This surgeon is correct that if the SNRB does not support the diagnosis of LRS, “it isn’t helpful”. That is the reason for the SNRB in the first place! A non-diagnostic block should point the diagnosis in another direction.

It is clear that the MRI notes LRS but the connection needs to be made between LRS and your symptoms. That is the reason for the SNRB. I disagree with this other surgeon regarding the CT scan. It would be helpful to know how much facet can be removed and what the anatomy of the operated facet looks like.

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 4, 2019 at 11:40 am

Post count: 15

#29972

Hi Dr. Corenman,

My pain specialist is willing to order a standing 1.5 T MRI, if that would be helpful in visualizing the dynamics of my spine as I stand? She would also order the CT, but asked if I wanted a CT “spec” and whether I wanted with and without contrast?

We also talked about the SNRB and that it may be difficult to do a lateral recess block, in particular. She said if she tried to block S1, most likely L5 should be blocked as well.

Thank you, again!

Donald Corenman, MD, DC
Moderator

January 4, 2019 at 4:03 pm

Post count: 8660

#29977

A standing MRI generally is a 0.7 tesla “Fonar” machine and is generally not helpful. Motion artifact makes the images less readable.

You already know what the potential diagnosis is (LRS). We just have to prove it. Your injection doc is correct in that both L5 and S1 roots will be blocked with a small volume TFESI at the L5-S1 foramen. The results from L5 are not relevant here as your films note no L5 root compression. The compression is at S1 and that root needs to be blocked.

You don’t need a spect scan CT with it’s attendant extra radiation. The STIR images off the MRI (which are negative in your case) have supplanted the spect scan in almost all cases.

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 5, 2019 at 8:16 am

Post count: 15

#30051

Dr. Corenman,

Should the CT be without and without contrast, or without? Also, she suggested a SNRB, then if it works a TFESI to provide some relief.

I have a feeling none of the regarded spine surgeons I see would study the CT to guide them when they perform a decompression (I am disappointed by that). Do surgeons typically use monopolar or bipolar for a single level? I would think the less tissue destruction the better for healing and for maintaining a good vascular supply to the nerve roots, especially for neurogenic claudication.

Thank you again, without you I really would be lost!

YNA
Participant

February 3, 2019 at 10:40 am

Post count: 15

#30086

Dr. Corenman,

Thank you again for your advice, but I am need of it again. As you know from our consultation, my left leg is far worse than my right leg, BUT I actually I have a considerable amount of aching pain (sometimes 9/10, despite large amounts of Gabapentin) in BOTH legs (calves and hamstrings). My surgeon thinks my amount of pain laying in bed on Gabapentin doesn’t match with my MRI.

I have an important question– at this point I can bear weight on my right leg. My left leg can bear weight, but is very weak. I’m very worried that after my bilateral decompression (God forbid), if I have a complication I will not be about to even walk to rehabilitate myself. Just yesterday I developed left-sided significant weakness (couldn’t plantar and dorsiflexion), went to the ER, and had an unchanged MRI. Some of the strength came back, enough to hobble to the bathroom. That scared me because I now need a walker to walk around my house because of significant left leg fatigue and deconditioning over the past 6 months.

What are your thoughts about doing just a left sided L5/S1 decompression vs. a bilateral L5/S1 decompression. If I cannot walk after surgery, I will be in trouble and I have not been lucky at all since my left L5/S1 microdiscectomy.

Thank you, again. I need to get better because my whole family is depending on me.

Donald Corenman, MD, DC
Moderator

February 4, 2019 at 11:35 am

Post count: 8660

#30092

It is always possible to have a complication from any surgery as you know well but this bilateral lateral recess decompression is a simple surgery. In fellowship programs would be performed by the fellow as it should be simple and has minimal complications. Yes, you had prior surgery which does incite some scar but a skilled surgeon should have no problem with this.

I would do bilateral as if you had only one side and had a great outcome, you would be highly disappointed that you did not do the other side under one anesthesia.

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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