Large left L5 extrusion - No back pain

Viewing 4 posts - 1 through 4 (of 4 total)

Author

Posts
hilfebitte
Member

September 4, 2011 at 7:41 am

Post count: 2

#4848

Dear Dr. Corenman,

today I am writing to you so other readers of this great website can benefit from the discussion. I have submitted my MRI already to your office for reference.
I have been diagnosed (MRI confirmed) with a large left L5 extrusion. Initially (~4 weeks ago) I had excrutiating pain originating from the L5/S1 lumbar region down into the entire leg, with extreme sciatica which completely demobilized me. Actually only laying down and crawling was acceptable. My night was interrupted with trying to find a position that was acceptable. At the time, a chiropractic assisted with pain treatment in particular electronic stimulation as well as massage. It all helped getting me out of pain and back to work.

A neurosurgeon advised laminectomy and discectomy as soon as possible based on the MRI and physical examination.
I do have no reflex on left foot, some weakness in left foot is evident compared to right foot. There is numbness in left foot since 4+ weeks. When I sit a lot (after work-office job) I often feel increased numbness and sometimes burning in the lower left leg/foot.
The only thing I do not have at all is back pain or any real pain for that matter. I am essentially pain free (no pain medication at all!). I am working and the only thing I feel is aggrevation of the constant symptoms like numbness and cramping in left leg. I don’t consider that pain, altough in fact it is really impacting my life/ability to work/etc.

The questions I have now are:
1) Is the nervous system in peril and is it really time for surgery given the limitations described above?

2) Is a microdiscectomy not a much more appropriate procedure? I am very oposed to a more invasive procedure such as the laminectomy. Or are these the same, what are the differences?

3) Why do I not have pain and what could that mean? Is it good or bad?

I greatly appreciate your time and dedication to this post.

Donald Corenman, MD, DC
Moderator

September 4, 2011 at 9:54 am

Post count: 8660

#4849

You report a large disc herniation at the left L5-S1 level. You unfortunately developed severe incapacitating pain in your leg associated with motor weakness. I’m glad you received chiropractic care that gave you relief but it would have been better to have seen a surgeon early. Two of the indications for a microdiscectomy are severe incapacitating pain and motor weakness and you did fit both qualifications.

If you had a disc herniation at L5-S1 with weakness, I assume you have weakness of the left calf muscles (gastrocnemius/ soleus group) and cannot tip toe while walking on that side. You report numbness and paresthesias (pins and needles feeling) in your left leg but no back or leg pain.

Based upon what you have told me, it appears that you need a microsurgery to remove the compressive disc from the S1 nerve. The fact there is no true pain is not necessarily a good sign as that portion of the nerve may not be transmitting due to possible compression and damage of the nerve root.

The surgeon advised a laminectomy and discectomy. I would assume that he meant a microdiscetomy which involves a very small laminotomy. If he wanted to do a laminectomy, that might have been overkill but I have not seen the MRI yet.

Surgeries proposed by different surgeons vary. I have seen fusions proposed for patients that have only needed decompressions, so I do not assume anything anymore. If you have a massive herniated disc that fills the canal and it cannot be removed without severe danger to your nerve roots, there is a very rare occasion that a full laminectomy can be necessary. I can tell you that I have never found it necessary to remove a herniation by that method but I can conceive of a situation where that might be necessary.

I would assume this surgeon means a laminotomy and microdiscectomy or discectomy (surgical procedure performed with loupes- not a microscope). It is the simplest of all spine procedures that I perform. If he is talented and meticulous as I assume many surgeons are, this procedure should go well without complications.

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.

hilfebitte
Member

September 5, 2011 at 1:20 am

Post count: 2

#4852

Dear Dr. Corenman,

thanks very much for the response.
To clarify, I am able to walk and tip toe. Walking on my toes and heels is possible. The weakness becomes visible since I can stand on one (right) leg and tip toe for 10 times without getting tired, however, on the left I am getting tired faster and bearly reach 10 times. The foot still supports going on my toes though as well as climbing stairs.

Indeed I had contacted the surgeon’s office and unfortunately only his assistance is able to answer the phone. To speak with himself I would have to make another appointment and last time it was a 2+ week wait period. That’s why I haven’t seen a surgeon sooner in the first place. I requested the MRI 3 days after I experienced the disabling pain for the first time. Then I had to wait 8 days to get it approved by the insurance, despite going to the ER where I was rejected. After I finally had the MRI, I needed to wait 16 days for an appointment.

Anyhow, his assistance specifically told me due to the size of my extrusion a laminotomy and microdiscectomy would NOT be possible and confirmed that he was planning on laminectomy.

I was able to find larger or comparable herniated disc MRI examples, where a microdiscectomy was performed in various online resources such as youtube videos and strongly feel a second opinion is adequate to ensure propre treatment.

By all means I am eager to avoid a major laminectomy and will hope for your opinion once you can see the MRI.
I will travel to Vail if that is what it takes to the get the right and appropriate treatment.

If you adivse not to wait another day (due to risk of permanent damadge) of course I’d also be thankful for a statement. Sometimes it’s maybe more damaging to wait than to go with the more invasive treatment. I really need help making that call, what do you think?

Donald Corenman, MD, DC
Moderator

September 5, 2011 at 5:55 am

Post count: 8660

#4855

By your report, your weakness is very mild so I don’t think there is any significant danger in waiting for surgery within a couple of weeks. Again- a full laminectomy may be unnecessary and even in cauda equina syndrome (massive hernations) I have never found it necessary to perform a full laminectomy. Still- there may be situations that a full laminectomy is required so I don’t want to throw stones.

IF you want to Fed Ex your films overnight to the office, please call DIana or Sarah at 970 476-1100 and explain your situation. They will put my face in front of the images that day and I will give you a call.

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.
Author

Posts

Viewing 4 posts - 1 through 4 (of 4 total)

You must be logged in to reply to this topic.

Donald Corenman, MD, DC

Average rating:

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.

Submit your review
First Name, Last Initial:
Email:
Review Title:
Rating:	1 2 3 4 5
Review:

Check this box to confirm you are human.
Submit Cancel

Large left L5 extrusion – No back pain – the right next step?