L5-S1 sequestration: prognosis and treatment?

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azzkel
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May 15, 2013 at 2:40 pm

Post count: 1

#8666

Greetings, Dr. Corenman! I’m writing on behalf of a good friend of mine, who is currently in hospital in Saint–Petersburg, Russia, due to disturbing back and left leg pain. He was hospitalized two weeks ago when the pain became intolerable. My friend is a 29 y/o male. He works as an engineer and spends a lot of time in front of the PC. Nevertheless he does exercises, walks a lot and rides a bike. He had a long history (~15 years) of lower back problems, with pain occurring sometime every year. In January 2013 the back started aching again and he did an MRI scan, here are the findings (I’ve translated them from Russian up to my knowledge and understanding) (picture here, I cannot properly attach the link, but you can copy and paste it into the browser):
imageshack.us/a/img24/7097/mityamri0801132.jpg

On the series of lumbar T1 and T2 weighted MR-images lordosis is normal. L5 vertebral body is posteriorly displaced by 0.8 cm. On T2 disc height and signal intensity of L4-S1 discs is lowered.
Dorsal medial L4-L5 disc bulge up to 0.6 cm, pressing on the epidural space and spreading into the adjacent foramina.
Dorsal diffuse L5-S1 disc bulge up to 1.1 cm, pressing on the wall of dural sac and spreading into the adjacent foramina, more on the left, and caudally along the S1 body up to 1.1 cm. Anteposterior width of the spinal canal is narrowed to 0.9 cm.
Dorsal Th12-L1 disc protrusion up to 0.3 cm, pressing on the anterior epidural space. Spinal canal width is lowered at the levels of disc herniations, Spinal canal signal on T1 and T2 is normal. Minor Schmorl’s nodules of Th12–L5 vertebrae. Vertebrae are normal in shape and size, signs of degeneration in vertebral bodies.
Impression: Signs of degenerative changes of the lumbar spine. Herniation of discs L4-L5, L5-S1(with caudal spread). L5 body retrospondylolisthesis.

The pain resolved without intervention, however one day in March all of a sudden the back pain returned and he lost feeling of his legs. He was given an injection by the ambulance team and prescribed some medicine. After a few days he could walk again, returned to work and even went to the swimming pool once, but then came the radicular pain in the left leg and partial numbness of the foot. He stayed at home for some time but the pain persisted and he decided to go to the hospital on April 26. Another MRI scan was made on May 3, here are the pictures and the findings (again translated from Russian):
imageshack.us/a/img809/9196/mityamri1030513.jpg
imageshack.us/a/img153/1258/mityamri2030513.jpg

On this lumbar T1 and T2 weighted MRI lordosis is normal.
Degenerative changes of intervertebral discs are observed: Th12-S1 level demonstrates lower signal intensity and disc height, L4–S1 levels show lower disc height.
Th12-S1 level shows right posterior paramedian disc bulge with a sagittal dimension of 3mm, pressing on the anterior wall of dural sac. Right foramen is moderately narrowed. Anteposterior width of spinal canal is 19 mm.
L3–L4 level shows dorsal disc bulge of 3 mm.
L4–L5 level shows posterior medial disc bulge, with a sagittal dimension of 4-4,5mm, pressing on the anterior wall of dural sac. Foramina are moderately narrowed. At this level anteposterior width of spinal canal is 16 mm.
L5–S1 level shows left posterior paramedian sequestered disc herniation with signs of caudal migration to lower 1/3 part of S1 vertebra, with a sagittal dimension of 12 mm and vertical size up to 15 mm, pressing on the anterior wall of dural sac and left S1 root. Anteposterior width of spinal canal is 11 mm.
Degenerative changes are observed in intervertebral joints as thickening and surface roughness of articular facets. Schmorl’s nodules of Th12–L5 vertebrae. Adipose degeneration and osteophyte growth on vertebral bodies. Paravertebral soft tissues normal.

Impression: Degenerative changes of lumbar vertebrae. L5–S1 left posterior paramedian sequestered disc herniation. L4–L5 posterior medial disc protrusion. Th12-S1 paramedian disc protrusion. Signs of spondyloarthrosis, spondylosis.

He was put on conservative therapy (laser therapy, magnetic therapy, some percutaneous injections), but there’s been no improvement since he had been hospitalized two and a half weeks ago, radicualr left leg pain and numbness in the foot are still there. He can barely walk more than 10 meters without rest, and the pain now interferes with his sleep.
A senior surgeon at the hospital said that a surgery is necessary, an endoscopic microdiscectomy in this case. Two other independent doctors (though not surgeons) gave similar views.

I’d like to ask your opinion: do the diagnosis and the choice of treatment look correct? Here in Russia medical services are sometimes a serious gamble, it’s hard to find a decent doctor.

Best regards,
Yegor

Donald Corenman, MD, DC
Moderator

May 15, 2013 at 8:30 pm

Post count: 8660

#8669

Based upon your description of his symptoms and the MRI evaulation, your friend has multilevel degenerative disc disease which has caused him intermittant lower back pain for years. He recently developed an extruded disc herniation at L5-S1 which is compressing his S1 nerve root (and possibly his L5 root too). With his significant symptoms, he more likely than not will require a discectomy.

I cannot comment on the quality of spine surgeons in Russia as I have no experience with medical care in that country. Try to fing the most experienced surgeon and ask the hospital staff what they think of his work.

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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