Multiple Surgical Opinions

Tagged: pars defect

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Donald Corenman, MD, DC
Moderator

June 15, 2022 at 11:12 am

Post count: 8660

#35123

Your comment “I did get some relief with the L5-S1” along with your symptoms “where initially pain was felt in the gluteal region and R hip. I had difficulty with sit to stand. This gradually went away. Now, my foot issues appear to be amplified with prolong sitting” does fit with a radiculopathy. Added to the symptoms, relief with an L5-S1 block points to the HNP right L5-S1 as your pain generator.

I’m not clear what surgeon B thinks but surgeon A’s advice; “do a laminectomy to see if we can unroof this and give him as nerves more space with a foraminotomy and medial facetectomy on the right side” sounds like a good idea. No fusion should be contemplated especially below a pars defect.

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.

leroydog
Participant

June 15, 2022 at 12:06 pm

Post count: 9

#35124

Surgeon B only recommended a microdisectomy at L5-S1 Level vs laminectomy. Are there certain scenarios with a herniated disk where a laminectomy is preferable than removal of disk? Or am I just getting lost in the nomenclature as there will be a laminotomy with a microdisectomy?

To be clear surgeon B did not think I was a fusion candidate at L5/s1 level.

Best,

Luke

Donald Corenman, MD, DC
Moderator

June 15, 2022 at 3:04 pm

Post count: 8660

#35126

I would agree more with Surgeon B that a microdiscectomy is all that is needed, While he is there, he could probe the foramen and if tight (unlikely), he could additionally perform a foraminotomy.

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.

leroydog
Participant

April 24, 2023 at 10:51 am

Post count: 9

#35611

Hi Dr. Corenman,
I just wanted to provide an update. I ended up having the microdisectomy done in August. I ended up doing the original MD surgery with surgeon B. (I think it is a natural human tendency to go with the surgeon who gives you the “best” news (least invasive)). Unfortunately, I didn’t really get any relief and feel like I am back to square on. Lots of right leg tingling, and sometimes pain in foot and calf. Lots of R gluteal pain and pain on the R SI joint. Surgeon B seems somewhat flumoxed on my symptoms now and I’ve lost confidence in him. Thus I returned to surgeon A, who was initially concerned about the pars defect. He reviewed my f/u MRI- thinks I reherniated and/or adequately was not decompressed on L5/S1.

I am also learning that different surgeons seem to be interpret imaging very differently and also have a different read on the radiologists reports. Is this normal?

This was the CT (April 2023):
1. Bilateral L4 complete spondylolysis with no osseous bridging and no evidence of L4
anterolisthesis. Mild diffuse disc bulge L4-L5 disc space with no significant central canal
narrowing or neuroforaminal stenosis.
2. Redemonstration of previous L5-S1 right hemilaminectomy and medial facetectomy and
redemonstration of what was proven to be prominent enhancing epidural fibrosis obscuring the
axillary portion of the right S1 nerve root. There is minimal/mild increase in mild to moderate
central canal narrowing at this L5-S1 level specifically in the region of the right anterior
lateral epidural recess.

Per Surgeon B; I have 5mm of spondlyolisthesis at L4-L5 as well as significant dis height loss at L5-S1. He is recommending L4-S1 ALIF with posterior instrumentation to repoair the pars fracture and address central and forminal stenosis. Obviously this is a big surgery and I am hesitant to get another surgery. I also want to be back to some activities I miss and be without nagging discomfort and pain. Are there any other approaches you would recommend? It sounds like trying another decompression at L5-S1 is off the table and for a “permanent” fix he is recommending a fusion secondary to spinal instability. My understanding is that both levels need to be fused secondary to the state of L5/S1.

Donald Corenman, MD, DC
Moderator

April 24, 2023 at 11:43 am

Post count: 8660

#35613

Part of the diagnosis is what is the prevailing symptom? Do you have predominant right buttocks and leg pain or more lower back pain?

To determine what the compressive mass consists of at L5-S1 (herniation vs scar), an MRI with gadolinium would be necessary.

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.

leroydog
Participant

April 24, 2023 at 11:52 am

Post count: 9

#35615

Predominately R butt/leg. I did do a MRI w/contract in December 2022. Neither surgeon has mentioned scar tissue being a factor.

Would it be helpful for me to do a formal imaging review?
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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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