L5S1 Revision Discectomy

Tagged: multiple microdiscectomies and now lower back pain

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Donald Corenman, MD, DC
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December 24, 2013 at 3:02 am

Post count: 8660

#9992

I would assume that when you “moved something” when the pain started, this action involved “BLT” (bend twist and lift) at the same time. This is the active position that more times than not, causes recurrent herniations.

Scar formation occurs on occasion after a microdiscectomy. Post operative physical therapy (nerve flossing) is designed to move the nerve root to prevent adhesions from adhering the root to any structure. Even with this therapy, adhesions can still form.

Herniations that occur after a prior herniation surgery can be much smaller and cause similar pain. Small extrusions can tent the tethered nerve root and cause this pain. The radiologist has to be very precise to recognize this small fragment.

A foraminal approach will not decompress the nerve root. This approach is designed to decompress nerve outside the canal (far lateral disc herniation- see website).

Adhesion removal or neurolysis by itself (no compression of the nerve root found on MRI) can be effective but the success rate is about 50%-a far cry from the greater than 90% rate for a microdiscectomy.

There are other mechanical causes for nerve root compression. Foraminal stenosis and lateral recess stenosis are two additional causes. See website for further explanation.

Fusion for nerve root pain is only undertaken for compression from alignment causes; spondylolisthesis and foraminal collapse.

There is always some risk that scar will adhere to the root but this is not common.

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

December 30, 2013 at 8:19 am

Post count: 8

#10014

Hi Doctor

I have sent you an MRI, and ask that this please be reviewed at your convenience. I believe its a recurrent herniation. It feels like one. The reading last March after my second discectomy surgery stated recurrent herniation moderately sized. This report does not state that, which contradicts the last report. This latest MRI was performed at one of the top hospitals in Boston, but I agree with you assessment that a precise reading is required. Considering my lack of back pain compared to the leg problems, and apparent spinal stability, i would agree a fusion doesn’t make sense. It’s been about 5 weeks of symptoms now with minimal improvement so far. If it’s herniated, and doesn’t improve significantly, would a third discectomy be out of the question? Again, this seems it stems from back to the second surgery (residual herniation or early re-hernitation). I can’t find much at all anywhere on all that I have have researched on anyone having had 3 discectomies. But It must be indicated and have a chance for success in some circumstances depending on the specific case.

Thank you.

Donald Corenman, MD, DC
Moderator

December 31, 2013 at 12:35 pm

Post count: 8660

#10020

In general, three discectomies should be discouraged. If the disc has failed three times, the chance of a fourth discectomy being successful is less than 50%. In addition, nerve roots cannot tolerate four separate compressions without significant damage to the root. Four surgeries also leads to greater scar tissue which is also detrimental to the root.

All in all, if there has been two prior separate microdiscectomies, the third surgery should be a decompression and a fusion to prevent further damage to the root.

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.

mc6613
Participant

August 12, 2019 at 7:33 am

Post count: 6

#30866

Hello Doctor,

Following up on this string, It’s been a while. As I have stated in the past I have 2 prior discectomies for L5S1, 1 in 2001 and a repeat in 2013. I have been able to be very active (playing ice hockey and coaching ice hockey over the past 5 years as well as coaching little league. However, I’ve been experiencing intense low back pain and mild sciatic pain in my left leg since June 2019 after a plane ride to Florida. Feels like there is a knife in my back at times. I have had this knife like pain flare up a few other times over the last 5 years. I have a long commute and sit most of the day at work. I have a recent MRI that shows a small L5 S1 Left Lateral Herniation (left over from the second discectomy, but the para central L5 S1 excised herniation did not re-occur. The MRI states this protusion is more or less the same size as past imaging studies from 2013 and 2015. I am going to attempt PT starting tomorrow and pain management (injection). My spine is stable, however, I am concerned that at this point, should I consider surgery? Or just continue to ride it out. If no surgery, where am I going to be in 5, 10, 15 years… Is TLIF the best approach for to decompress the disc/scar tissue from the 2 previous discectomies? What is activity level like after TLIF of L5S1? Also, what about spinal cord stimulator implantation, any thoughts on this? I can send you my MRI. I believe I requested a package last week to send an MRI, would that package be coming in the mail? Thank you for you time.

Donald Corenman, MD, DC
Moderator

August 17, 2019 at 9:32 am

Post count: 8660

#30895

“I’ve been experiencing intense low back pain and mild sciatic pain in my left leg since June 2019 after a plane ride to Florida…2 prior discectomies for L5S1, 1 in 2001 and a repeat in 2013”.

Symptomatic degeneration of the disc after two microdiscectomies occurs in at least 10% of the population. This sounds like your problem. I would assume you have symptoms somewhat similar to IDR. See https://neckandback.com/conditions/isolated-disc-resorption-lumbar-spine-idr/.

This condition is not dangerous but can be quite disabling. Read this https://neckandback.com/treatments/conservative-treatment-mechanical-lower-back-disorders/ but you might eventually be a candidate for a fusion of this level.

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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