L5S1 Revision Discectomy

Tagged: multiple microdiscectomies and now lower back pain

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Hoosemec
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February 21, 2013 at 11:53 pm

Post count: 8

#8050

Hello Doctor Corenman,

Your website is an excellent source of information, and the time you take respond to concerns of people is quite remarkable.

I am a generally fit 46 year old man 5’9” 185 lbs. Two weeks ago I had a revision micro/discectomy/foraminotomy performed on the L5S1 level. I had been suffering some relapses for the last 3 years, but 2.5 months ago, I ended up with severe 10 out of 10 pains from sciatica, with very little relief over that duration and a huge downgrade to quality of life. The MRI report stated “small amount of enhancing scar around the left S1 nerve, disc thinning and degenerative changes in disc, moderate left Para central disc herniation/protrusion impinging the left S1 nerve root”

The original discectomy was performed in 2001 for left leg pain and some foot weakness. It was an open procedure. It was discovered during the revision surgery that the ligamentum flavum was laid back down and left in place after it had been dissected during the original procedure. This resulted in an excess of scarring around the thecal sac and nerve. The Surgeon firs had to decompress this left over ligament first then proceeded to remove the offending disc (about the size of the tip of a pinkie finger). The nerve was not as mobile due to scarring in, and therefore, the Surgeon had to push the herniation down in order to visualize and remove it due to the nerve’s limited mobility.

My main questions are:
1. I awoke with numbness on the left side of my left foot, my left calve, and back of left thigh. I did not have this prior to the surgery at any time. I have read this can occur more frequently in revision surgery, what are your thoughts?
2. My sciatica was gone after the procedure for the first 2 days, then crept back about 20% just in the left butt and slightly down the left back of leg to mid thigh. It was much more intense and far reaching before the surgery. However, I can intensify the sciatica by just palpating my back in the area of the surgery (push and feel more sciatica). This has me very concerned. I had this issue prior to the surgery and it was much worse then. Is this lingering inflammation, is this normal?
3. I was told I could return to work after about 1.5 weeks. It’s been two weeks. I am a Project Manager am required to drive 45-60 minutes each way to work, then sit in meetings that can last anywhere from 1 to 2 hours or longer. This seems aggressive and I don’t feel I could handle the discomfort at this time, nor would I want to compromise my recovery. What are your thoughts on returning to work with for my type of work?
4. Where can I find the best advice and exercise to mitigate scarring during the healing process?

Thank you.

Donald Corenman, MD, DC
Moderator

February 22, 2013 at 1:56 am

Post count: 8660

#8051

The numbness that you find present might have been present prior to surgery but “covered over” by pain in the same area. When the pain abates, the numbness is noted. Manipulation of the nerve during surgery can also create numbness that was not present prior to surgery. Normally, this numbness will disappear over time.

Pain that was not present immediately after surgery can recur in some patients but not normally to the same intensity as prior to surgery. This can occur from the inflammatory cascade (it takes some time for inflammation and swelling to occur), from hematoma (a small amount of blood in the canal can cause inflammation or compression) or from a recurrent herniation (rare but known to happen in the immediate post-operative period).

There is a very small change of the presence of chronic radiculopathy (a preexisting injury to the nerve from the herniation-see website) but that is unlikely.

Return to work depends upon the patient and occupation. If you were one of my professional athletes, you might not go back to competition for 8 weeks. If you were an attorney or CEO, you might go back to work in one week (part time-light duty). Some patients walk out of the hospital without any symptoms and some are uncomfortable for two weeks. Sitting is always the most symptomatic of the prolonged positions in the immediate post-operative period.

You normally want to start nerve glides in about 10 days after surgery. The root should be free of adhesions immediately after surgery and the normal response of the body is to form scar tissue. The nerve root should move about one centimeter with leg or back motion. This is why physical therapy is helpful for prevention of adhesions. The technique is called nerve flossing and is self-descriptive.

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.

Hoosemec
Member

February 23, 2013 at 9:24 am

Post count: 8

#8061

Doctor, thank you for your previous responses.

How long before I can get an MRI to clearly see if the disc reherniated?
Should I request an injection now to relieve the pain?

Thank you.

Donald Corenman, MD, DC
Moderator

February 24, 2013 at 12:00 am

Post count: 8660

#8069

This depends upon the physical examination and your complaints of symptoms as compared to the symptoms prior to the surgery. I would have a patient in your position try an oral steroid first (if you had no contraindications). If poor results and symptoms were increasing, I would consider a new MRI before a suggestion of an injection.

I use the MRI prior to an injection as the MRI could reveal a small amount of pooling blood (hematoma) and this could be aspirated prior to the injection.

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.

Hoosemec
Member

February 27, 2013 at 6:45 am

Post count: 8

#8091

Hello Doctor

I have tried a 5 day pack of steroids which had reall no noticeable effects. I would say the sciatica I feel is mild and varies slightly located in the left buttock mostly and not below the knee. Im able to walk about 3 miles a day currently. I’m scheduled for an mri with contrast next week. Which will be about 4 weeks out from the surgery. No real conclusive straight leg test mostly muscle tightness. The mri probably won’t clearly differentiate between scar tissue and disc so early on I understand. My question is if a herniation is found, even if its small, would removing it sooner than later pose any issue ? That would be a third discectomy but perhaps that piece should have come out in the second surgery? I really want to get back to being active. If no herniation is found and its a resultant damaged nerve at least I would know that and could just work through the pain at that point and hope it gets better with time The thought of having another herniation just after an operation and leaving it there would seem like a massive setback. My Back so far has no stability issues.

Thank you.

Donald Corenman, MD, DC
Moderator

February 27, 2013 at 4:30 pm

Post count: 8660

#8097

If your symptoms are mild and significantly better than preoperative symptoms, I would give it more time for improvement. Contrast will differentiate recurrent disc herniation from granulation tissue. I would not jump into surgery too quickly based upon your current symptoms.

A third herniation normally points to a fusion as the nerve gets “battered” if compressed by herniation three times. In your case however, consideration could be given to a repeat microdiscectomy if the new herniation occurs in the immediate postoperative period.

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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