Lumbar discogram to eliminate disc source of pain

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StephenF
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December 22, 2021 at 6:14 pm

Post count: 5

#34703

Doc,
I had a conversation with you 2 years ago regarding my cervical disc issues. Over time this issue has been mitigated by avoiding certain neck positions .
For the last 2 years I have been dealing with peripheral neuropathies bilaterally from the waist down.
A small sampling of my last clinical notes from my latest PMR.

RADIOLOGICAL REVIEW: I reviewed a CT scan of the cervical spine from 4/14/2021. This is notable for intervertebral disc replacements at C5-6 and C6-7. At C4-5 there is a disc
osteophyte complex with facet arthrosis and uncovertebral spurring on the left resulting in severe neuroforaminal stenosis at this level. At C5-6 there is mild uncovertebral spurring
and facet arthrosis causing mild to moderate bilateral foraminal stenosis. At C6-7 there is prominent uncovertebral spurring on the left resulting in severe neural foraminal stenosis.
There is mild neural foraminal stenosis on the right due to uncovertebral spurring. At C7-T1 there is mild facet arthrosis but without central or foraminal stenosis.
I reviewed and interpreted an MRI of the lumbar spine from 5/1/2020. There is mild disc bulges at L2-3, L3-4, and L4-5. Mild bilateral facet hypertrophy noted at L3-4, L4-5, and
L5-S1. There is mild bilateral neuroforaminal stenosis at L5-S1 without nerve impingement. No central stenosis. I reviewed and interpreted images of the lumbar spine MRI from
8/24/2021. This is notable for mild degenerative disc changes with minimal bulging at L3-4, L4-5. There is a tiny annular fissure at L2-3 centrally with no central or foraminal
stenosis. There is mild facet arthropathy at L3-4, L4-5, and L5-S1. There is no central stenosis. There is mild left L3-4 foraminal stenosis and mild bilateral foraminal stenosis at
L4-5. Fatty infiltration of lumbar erector spinae muscles noted consistent with deconditioning.
IMPRESSION: Stephen is a pleasant 59-year-old gentleman with:
1. Low back pain.
2. Lumbar degenerative disc disease.
3. Cervical spinal stenosis.
4. Cervical radiculopathy.
5. Cervical myofascial pain syndrome.

The PMR tried multiple injections including a medial branch nerve block with no results. The only injection that I seemed to get relief from was a midline shot between 3&4- and that was after 10 days , and it only lasted 4 days.
My question is -are discograms mostly used by surgeons when considering surgery? Without posting all of my radiology reports I can say that I had a posterior midline tear at L2-3 that was on my 2020 MRI. The latest MRI shows it as a tiny tear-so there has been some morphology with this disc. None of my PMR doctors seem to give that tear a thought. Even after I had an episode(strain) where I couldn’t raise my legs off my seat and I was in terrible pain. They kept shooting L4&5 and it wasn’t helping. At this point I want to have a discogram, but the PMR rather declare me myofascial based on fatty tissues in my MRI.
I am tall and thin but in very good shape. I can do 30 push-ups at a time and I have been working on my core for months now(because everyone says core,core-though it wasn’t weak. In the beginning I had NO back pain, just the peripheral stuff in my feet, thighs, butt, hips and I could touch my toes. Now I have to avoid curling my back in any way because of the pain. The way I read it , there is a lot of innervation of nerves around the higher lumbar. Would a discogram show whether or not the annulus fibers healed correctly?
Not diabetic. I’ve had a skin biopsy at the Cleveland Clinic that showed no nerve damage. The neurologist declared me idiopathic, and she could do nothing else for me. EMG is normal. MRI Neurogram showed nothing remarkable.
Age 59, 6′!” 155lbs.

Thanks for your time and happy holidays

Donald Corenman, MD, DC
Moderator

January 11, 2022 at 12:07 pm

Post count: 8660

#34712

Disc problems (short of a disc herniation that compresses nerve roots) will not cause nerve pain. With a normal EMG and normal biopsy, this leads to a diagnosis of idiopathic neuropathy. This simply means that we have not discovered the cause as our testing is not precise enough. Discograms will only diagnose disc pain generators and will not be helpful in your 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.

StephenF
Participant

January 14, 2022 at 10:57 am

Post count: 5

#34740

I thought I read this differently as far as the disc being a pain generator beyond a herniation. With regards to a tear leaking out the pulpous and burning nerves, and or the annulous fibers healing inward to cause instability of the disc,etc….
Does a good EMG mean that the nerve path is good and void of a sciatic neuropathy? But that doesn’t mean that the nerve can’t be a path for radicular pain?
I guess I wonder how you are so sure (with all due respect), based on the info I supplied, that the disc is not the pain generator?

Thanks Doc
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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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