Massive Herniation After Spinal Fusion

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Ahern
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September 9, 2013 at 10:49 pm

Post count: 3

#9350

Hi Doctor – I had a l5/s1 fusion two years ago for sponylothesis. Two months ago I suffed a 18×11 mm herniation at the l4/5 level. Extruded, but I do not think a fragment.

Pain in buttocks (both sides) and back and burning in penis. Sometimes left foot sensations and leg spams.

Surgeon who performed fusion surgery wants to do a microdisctomeny, which he said will help get me back to preherniation pain. More conservative surgeon says herniation pain will improve with time and do not do surgery. Didn’t say there were any downsides, but said that is what he would do if it were his back.

I am only 43 years old and father of 3 young children. There is not much disc left at l4/5 and I have ddd at l4/3. All I can think about is 10 years from now and a triple level fusion.

What do you think the chances of this hernation dissolving, shrinking on its own so that it is not symptomatic or do you think my fears will become reality?

Thanks in advance.

Donald Corenman, MD, DC
Moderator

September 10, 2013 at 6:21 pm

Post count: 8660

#9352

You do have a dilemma in decision making. I will assume that you do not have any motor weakness (especially of the tibialis anterior or the gluteus medius muscles-see website under “conditions’; “nerve injuries and recovery” then “symptoms of lumbar nerve injuries”).

This weakness will be discovered in a thorough physical examination which I assume you have already underwent. If you have motor weakness, in my opinion you need surgery much sooner than later. I will also assume that you do not have cauda equina syndrome (see website) as that disorder is also a surgical condition. If you do not have either condition, you have to consider the benefits and risks of waiting.

The benefits of waiting are that you avoid another surgery and the potential risks of that procedure. The risks of waiting are that this herniation is quite large and causing compression of the nerve root but not enough to cause motor weakness at this point. You have a chance of developing chronic radiculopathy (see website) which is a permanent condition of pain generation.

The problem is at this point, there is not a study that can answer two questions. How long do you have before surgery would be ineffective to prevent chronic radiculopathy? What percentage of patients in your situation will develop chronic radiculopathy? I am gathering data to write this paper but it will be some time before it is out.

Unfortunately, you do have the genetic traits that promote degenerative disc disease but that does not mean that you are going to be a fusion candidate in the future. Read the sections regarding back care on this website and find a good Pilates instructor who can educate you in core strengthening.

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.

Ahern
Member

September 11, 2013 at 3:12 am

Post count: 3

#9356

Thanks Dr for responding to my post so quickly. One more question, what are the chances the herination will dissolve on its own? Does that frequently happen or myth? I have read that the big ones typically dissove, but unable to get any concrete answers.

Donald Corenman, MD, DC
Moderator

September 11, 2013 at 9:56 am

Post count: 8660

#9357

The disc herniation can reduce in size over time. This has a higher likelihood to occur if the herniation is very hydrated (full of water) which can be noted on MRI of high signal on T2 images. This water can be absorbed somewhat quickly and reduce the size of the compressive force. The herniation can also migrate if it is a free fragment and exit through the foramen. It will eventually “get stuck” on the surface of the psoas muscle and cause no harm.

These possibilities are balanced by the fact that this fragment can also get “stuck” in its position and continuously compress the nerve. This can cause chronic pain in the nerve root. I had just seen a patient today who had a herniation six months ago. She elected to wait and had improvement but continued leg pain and still has a sensitive nerve root.

There is no right or wrong answer to surgery for herniated disc without motor weakness. I think the die is cast if there is motor weakness (surgery is needed).

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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