Large Centrally Herniated Disc at L5-S1

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rkassam
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February 14, 2012 at 1:12 pm

Post count: 8

#5572

About 4 months ago I started experiencing low back pain on my right side. I went to my family doctor who prescribed me naproxen 500mg x 2/ day. After about a month, the pain got better in my back, but then I started to feel severe pain in my right butt, ankle and foot. This pain was accompanied my pins, needles, and numbness in my right foot. It got worse when I laid down, so I had a lot of sleepless nights.

I went for an MRI and the radiologist results were:

At l5-S1. there is a large central disc herniation which occupies approximately 50% of the cross sectional area of the spinal canal. This is slightly asymetric toward the right side. This probably impinges on the S1 nerve roots bilaterally, right greater than left within the right lateral recess of the spinal canal.

At L4-5 there is a large posterior disc herniation centred right paracentral which occupies just under 50% of the cross sectional area of the spinal canal. This probably impinges upon the right L5 nerve root within the right lateral recess of the spinal canal.

No other significant findings are appreciated.
–

My family doctor suggested I see a orthopedic surgeon as my MRI had significant findings.

I got an appointment for two months later, so I decided to do physical therapy in the mean time.

I did 6 weeks of physical therapy focusing on the McKenzie protocol. My pain and numbness has diminished greatly. I have intermittent tingling in my right foot with some pain in my ankle on and off. However this pain is quite tolerable.

My question is that with such a reduction in pain and being able to get through my day, am I still a candidate for surgery?

The main thing that has me worried is the “centrally herniated disc”. I keeping reading online that this can lead to Cauda Equina. Is it possible that this herniation can get bigger and lead to that. Hence, it needs to be surgically treated now.

Any input would greatly be appreciated.

Donald Corenman, MD, DC
Moderator

February 15, 2012 at 8:56 am

Post count: 8660

#5575

You have two relatively large herniated discs at L4-5 and L5-S1 which have appeared to compress the right sided nerve roots. The typical presentation of numbness, pins and needles and pain accompanied the nerve compression. I will assume you have no motor weakness of the foot dorsiflexors and plantar flexors (you can walk on your heels and toes for some distance without fatigue or weakness).

You have participated in physical therapy for the last six weeks and have improved significantly. The symptoms now are annoying but not disabling. Again- assuming you have no motor weakness, you can try to continue conservative treatment.

You have a genetic predisposition for herniations based upon the 2 levels and the large size of the herniations. If the herniations stay the same size and do not enlarge (recurrent herniations), the chance of cauda equina syndrome is remote. Over time, these herniations will shrink down and become less inflamed. There is a chance of recurrent herniation with or without surgery and no one knows the exact incidence of that possibility in your particular case.

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.

rkassam
Member

February 17, 2012 at 6:27 am

Post count: 8

#5582

I have no motor weakness of the foot dorsiflexors and plantar flexors that I have noticed. I seem to be able to walk on my heels and toes for some distances.

I realize that surgery is not a 100% cure all as there is always a risk of re-herniation. So if pain is tolerable why go for surgery.

However, I am confused about this whole large centrally herniated disc situation. As this type of herniation is not as frequent it is not as easy finding information on it.

From my research in scientific journals, I have found that a central prolapse is apt to increase in size, which may develop rapidly. Since this type of prolapse can lead to nerve damage that may not be fully recoverable even after surgery, it maybe advisable to perform surgery in order to prevent progression. That is it’s better to do the surgery in a non emergency situation were there is no risk of irreversible nerve damage than in an emergency situation.

As I am not from a medical background, I might just be reading to much into this. What do you think?

Thank you for your input.

rkassam
Member

February 24, 2012 at 7:43 am

Post count: 8

#5634

bump

dustingfab
Member

February 24, 2012 at 10:29 pm

Post count: 27

#5642

rkassam post=1273 wrote: I have no motor weakness of the foot dorsiflexors and plantar flexors that I have noticed. I seem to be able to walk on my heels and toes for some distances.

I realize that surgery is not a 100% cure all as there is always a risk of re-herniation. So if pain is tolerable why go for surgery.

However, I am confused about this whole large centrally herniated disc situation. As this type of herniation is not as frequent it is not as easy finding information on it.

From my research in scientific journals, I have found that a central prolapse is apt to increase in size, which may develop rapidly. Since this type of prolapse can lead to nerve damage that may not be fully recoverable even after surgery, it maybe advisable to perform surgery in order to prevent progression. That is it’s better to do the surgery in a non emergency situation were there is no risk of irreversible nerve damage than in an emergency situation.

As I am not from a medical background, I might just be reading to much into this. What do you think?

Thank you for your input.

Thank you for posting your last question. Is it better to go ahead with surgery when the current situation is non emergent or wait till you can no longer tolerate the pain and the situation is emergent.

Donald Corenman, MD, DC
Moderator

February 24, 2012 at 11:13 pm

Post count: 8660

#5647

The answer to your question “Is it better to go ahead with surgery when the current situation is non emergent or wait till you can no longer tolerate the pain and the situation is emergent” is multifactorial. By understanding the risks of surgery with the risks of a non-surgical approach, you can make an informed decision.

Let us go over the indications for surgery in your case. Motor weakness, cauda equina syndrome and intolerable pain are the indications for surgery. You do not have either of the first two and you are improving with physical therapy so the third one is diminishing. Yes, there is a risk associated with living with the herniations but there is a risk with surgery too.

The risk of cauda equina syndrome is what appears to be your biggest fear if either herniation enlarges. Yes there is a risk but it is very small. I see only 1-2 patients a year with cauda equina syndrome from large herniations from a total population of about 1000 patients. Surgery therefore depends upon your risk aversion. The risk is 0.2% if you use the above statistics. The risk of recurrent herniation is about 10%.

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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