Myelomalacia

Tagged: myelomalacia and incision break-down in posterior neck surgery, Myelopathy

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Malapp10
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January 11, 2019 at 11:37 am

Post count: 2

#30060

Dear Dr. Corenman,

Thank you for maintaining this forum. It is nice to have a place to go to read about a difficult diagnosis and have an expert who is willing to comment on it. Two years ago, I was diagnosed with spinal stenosis and a ruptured disk at my C4 through C6 levels. The diagnosis was made with a physical exam and an MRI. I had surgery to correct the problem. The surgery went horribly wrong. I had to have two more surgeries over the next three weeks. I developed a severe infection that required two wash out surgeries. Two more MRI’s were done. In none of the MRI’s was Myelomalacia ever mentioned

During the first surgery, the surgeon attempted to place a catheter and he made a massive mess of it. He scratched my urinary track and prostate gland and ultimately had to have a urologist paged to the operating room to complete the procedure. Soon after the the two washout surgeries I developed a large seroma that covered the top half of my back. After three months of pick lines, massive doses of antibiotics, and other therapies the seroma opened where the scar from the original surgeries was. The opening ultimately became the size of a football before anyone could figure out how to close it. It should be noted that I was now being treated at Jackson Memorial Hospital and with University of Miami doctors. Another surgery was done to attempt to close the opening.

We were now about 4 months into this nightmare and I was going through daily treatments in a bariatric chamber when the doctor who managed the unit of the University of Miami Hospital realized that there was a rather large area of this horribly gross looking mess that was missing skin and allowing more infection into my body. She operated on me doing another skin graph. I was suffering through intense pain throughout the entire ordeal. Another MRI was done and this time they realized that I also had Myelomalacia that started at the level where the first surgery was done and extended into my thoracic spine.

Now a team of doctors from the world famous Miami Projects and the head of Plastic Surgery for the University of Miami who is also world famous for something I’d rather not go into were assembled. This time another fusion was done from the next two levels of my spine down and an enourmous muscle flap was done to cover the mess from the first four surgeries. This time they also removed the original hardware from the first fusion.

This surgery was was incredibly painful and I was now taking massive doses of opioids to control my pain. After a total of ten surgeries, an interthecal pump was installed and I am now up to 9 MG’s per day of morphine that is not controlling my pain, we are changing to dilauded next month.

Finally, we are at my question, it is my understanding that myelomalacia is caused by a traumatic injury of some sort. I had no such injury. There was no diagnosis of myelomalacia until the fifth MRI was done. Is it possible that the surgeon who did the first surgery caused the myelomalacia by improperly utilizing his surgical tools and the foot print of these tools was the cause. Is there any relationship between the infection that was ultimately determined to be Stenotrophomonas maltophilia that likely entered my body through the danged urinary track and the myelomalacia and lastly, is there any hope that my pain level will subside and is there and that the myelomalacia will not ultimately kill me due to respiratory arrest.

Thank you for your time.

jerryellis
Participant

February 19, 2019 at 12:03 pm

Post count: 2

#30169

I’m very sorry your going through this. I dont know you but I know your suffering and it’s kind of hard to read people’s stories on here because I cant find the words to say that might offer some encouragement. I myself am suffering and I’m terrified every night to lay in bed because I’m scared I wont be able to move when I awake. And to be honest where I live I cant seem to get answers from anyone because they are saving each others ass.i think a chiropractor broke my neck trying to give me lumbar treatment. Makes no sense does it. I sincerely hope you start feeling better and you get back to a better quality of life. I think we both are lucky to find Dr Corenman and I know if anyone can help you if would be him. Keep us posted

Donald Corenman, MD, DC
Moderator

February 23, 2019 at 6:45 pm

Post count: 8660

#30176

You had some very bad complications after your posterior neck surgery which I assume was a C4-6 decompression and fusion with hardware surgery.

The problem with your tube inserted into your urinary tract is highly unusual but does occur. I have seen it occur 3 times in 30 years of surgery. The problem is that the prostate gland enlarges or a prior infection causes scar and makes the ureter (the tube that carries urine from the bladder) kinked so that a tube cannot be passed blindly. This would then require a urologist with a scope to place the tube, a surgical procedure. If this occurs, I typically cancel the operation that day to allow the urinary tract to heal and to prevent bacteria from contaminating the surgical site.

Your problem with complications from your neck surgeries is bigger. You had a posterior surgery initially for cord compression. I generally stay away from posterior surgery for cord compression due to generally poorer wound healing and longer time to fusion in the back of the neck. That being said, I did do a front and back neck surgery yesterday so there are times it is necessary.

It is not surprising that you developed a posterior wound infection, especially at a university hospital. These posterior neck surgeries have a higher infection rate and your wound probably became infected. The typical treatment for this is a surgical debridement (surgically cleaning any non-viable tissue and placement of a wound vac (a sterile piece of sponge placed under suction) to draw out the infection and allow the wound to close. I assume that did not work.

You then had an attempt at a skin graft. That is a technique where a patch of skin (normally taken from your thigh) is transplanted to the open wound to get this new skin to grow over the wound. That sounds like it failed.

I’m sure the discussion on how to close your open wound was a hot topic in this group. Finally someone decided to get a new MRI and found further compression of the spinal cord below your original C4-5 levels (at C6-T1) with myelomalacia. Myelomalacia is a narrowing or thinning of the spinal cord generally due to injury. “Myelo” means spinal cord and malacia is a “wasting away”. Myelomalacia occurs when there has been injury to the tracts in the cord, normally from cord compression or injury. The spinal cord is a raceway of nerves and if some become damaged, they atrophy which narrows the cord (“malacia”).The question is whether the myelomalacia developed from the original compression of C4-6 or developed after the initial surgery. There is no way to tell if the original compression was significant. Why the levels below were not addressed at the first surgery I cannot speak to.

The discovery of further compression had this surgeon thinking to “kill two birds with one stone”. She could decompress and fuse the C6-T1 levels while during the same anesthesia, a plastic surgeon could “swing a flap”. That is, take some nearby tissue and move this tissue into the non healing defect to finally allow the body to heal the open wound.

My difficulty in accepting that is that you already had an open wound presumedly infected and to do further surgery with metal placement in an infected wound would not be my first choice. Metal generally allows bacteria to “stick” to it so an open wound makes this a precarious situation.

I could have considered an anterior approach (ACDF) as this type of surgery is more effective and has a much better healing rate.Of course, there may be variables that are not apparent to me that could lead to a different conclusion.

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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