Need info about MRI and pain in low back

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mikenite
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September 2, 2011 at 6:19 am

Post count: 4

#4836

I have an Mri that States: “FINDINGS: Lumbar vertebral body height, alignment and signal”
“intensity are satisfactory.”
“The conus shows a normal configuration and location.”
“Disk space height is relatively maintained. Also T2 disk signal is”
“present at L5-S1 level representing degenerative changes.”
“The L1-L2 level demonstrates no impingement of the neural elements.”
“The L2-L3 level demonstrates no impingement of the neural elements.”
“The L3-L4 level demonstrates mild facet hypertrophy. There is no”
“impingement of the neural elements.”
“The L4-L5 level demonstrates moderate facet hypertrophy and bulging”
“of the annulus. There is no significant central canal stenosis. Mild foraminal narrowing is present.”
“The L5-S1 level shows a bulging annulus and bilateral facet”
“hypertrophy. There is increased bulging towards the left, causing impingement of the left S1 nerve root as was previously noted. Mild bilateral foraminal narrowing is present.”
“IMPRESSION: MRI of the lumbar spine has not significantly changed”
“from the examination of 09/05/2010. Degenerative changes are seen at”
“L4-L5 and L5-S1 levels.”
But when I look at the mri image the L5-S1 arent in alignment and it seems like that where my pain is origining from. I do have some leg and buttock pain that shoots down my leg from time to time with servere fair ups. I’ve done the nonevasive treatments 2 epidural injections and meds that hasnt helped. I try to stay active but walking,sitting and standing really make thngs worse so I walk with a cane to help with support.The doctor that applied the injections stated that my left leg is weaker than the right. I havent returned to work because of the pain and not being able to stand or walk for long. My specialist then referred me to accupuncture treatment . why…
I need to get my life back and get back to work.
If possible could I send a mri image to get you opinion.

Donald Corenman, MD, DC
Moderator

September 2, 2011 at 8:55 pm

Post count: 8660

#4841

Let us start from the beginning. The MRI is applicable only after we have an idea of the symptoms, then the history of how this started, what treatment you have had and any consultations and opinions. A physical examination is important to narrow the potential disorders and then the MRI is used along with standing X-rays including flexion and extension X-rays to determine what the disorder is.

Obviously, a physical examination can’t be performed over the internet (at least at this time) so we am limited to vignettes.

Let us start with symptoms. You state “I do have some leg and buttocks pain that shoots down my leg from time to time with severe fair ups”. Also “I try to stay active but walking, sitting and standing really make things worse so I walk with a cane to help with support”.

So you have buttocks and leg pain but no lower back pain. You do not note the side of leg pain. Buttocks and leg pain normally originate from the same source, compression of the nerve root. Walking and standing increase the pain. This is normally generated from foraminal or lateral recess stenosis (see web site). Use of a cane normally is necessary if there is motor weakness (you don’t state if you have weakness- only a reference from the injection physician) or from the need to bend forward while ambulating. Forward bending with walking is caused by a deformity of the lower or mid back (unlikely in your case) or antalgia (the need to assume a particular position because of pain- more likely in your case). Did you get any relief from the epidural injections?

So possibly we are looking for the cause of foraminal stenosis or lateral recess stenosis. You state the MRI notes the L5-S1 segment is not in alignment. The radiologist did not note this on the MRI but the lack of notation of that finding is not unusual. If there truly is a slip of L5 on S1, the cause most likely would be from degenerative spondylolisthesis or isthmic spondylolisthesis (see web site).

Degenerative spondylolisthesis is caused by significant wear of the facets where in isthmic spondylolisthesis, the facets are normally pristine as they are not loaded because of the old pars fracture. The MRI report states “”The L5-S1 level shows a bulging annulus and bilateral facet” “hypertrophy. There is increased bulging towards the left, causing impingement of the left S1 nerve root as was previously noted. Mild bilateral foraminal narrowing is present.”

Bilateral facet hypertrophy is a code word for significant facet arthritis or severe wear of the facets. This goes along with the diagnosis of degenerative spondylolisthesis and your observation of the slip at L5-S1 (you possibly picked it up when the radiologist missed it!) may complete the picture.

Putting it all together leads to a possible degenerative spondylolisthesis of L5-S1 with either foraminal or lateral recess stenosis compressing the L5 or S1 nerves (or both). Your nerve root is compressed with standing and walking forcing you to lean forward which requires a cane for ambulation. I assume you are in much less pain with sitting or lying down with your knees bent or standing and leaning over a counter.

If this is correct, there are many disorders that can be helped by acupuncture but this is not one of them. Depending upon the length of time you have had this and the treatments you have undergone, you might be a candidate for surgery. The surgery would depend upon the stability of the vertebra and that can be determined by both the MRI and standing X-rays including flexion and extension views.

If you would like, you can send me the MRI and X-rays and I would be happy to throw in my 2 cents. Call the office and ask for Diana or Sarah at 970 476-1100.

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.

mikenite
Member

September 4, 2011 at 12:48 pm

Post count: 4

#4850

Sorry I do have low back pain, I do get relief laying down but if I’m on my feet for any length of times I get that really bad pain,which feels like my lower spaine area is being compressed or something. As far as the epidural go I did not get any relief from the 2 injections at all none. I think the disk has worse out or something that what is feels like too. I have been dealing with low back pain for almost 15-20 years, it seems like over the years it has gotten worse and worse, I tried adjusting my activities to compensate for the pain. But now everything seems to cause it fair up. So I try not to do too much. You
state:
Bilateral facet hypertrophy is a code word for significant facet arthritis or severe wear of the facets. This goes along with the diagnosis of degenerative spondylolisthesis and your observation of the slip at L5-S1 (you possibly picked it up when the radiologist missed it!) may complete the picture.

How would you go about correcting that problem:
I going to try and paint a picture of the L5 S1 disk area, If you looked at my S1 disk the edge of the disk that faces my back on both disk, the S1 seemed to tilt in towards the
L5 and the edege of the S1 disk appear to hit the L5 disk, if that makes sense.

So with everything do you think i would be a candidate for surgery, if so what type of surgery would you suggest.

Donald Corenman, MD, DC
Moderator

September 5, 2011 at 5:09 am

Post count: 8660

#4853

Incapacitating lower back pain for 15-20 years with failure of conservative treatment means you could be a surgical candidate. It depends upon the results of the physical examination, the MRI and X-rays, possible further testing (discograms and/or SNRBs) and your expectations of surgical results.

Let’s just assume your discs above L5-S1 are pristine on MRI and your alignment of all discs but L5-S1 on X-ray including flexion/extension films is within normal limits. If your examination makes the diagnosis unclear or there is suspicion of a possible pain processing issue (abnormal brain processing of pain), you would need discograms (see website). If your diagnosis was crystal clear, you might not need further workup.

If everything was crystal clear on the diagnosis, most likely a TLIF of L5-S1 would have a 85-90% chance of reducing your lower back pain by 2/3rds. This means that if one hundred patients were operated on with your exact diagnosis, 85 to 90 individuals would agree that they have approximately 66% relief of the previous lower back pain.

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.

mikenite
Member

September 5, 2011 at 2:13 pm

Post count: 4

#4857

Could you please explain the type of results the examination would have to indicate, and what make the examination and diagnosis unclear or suspicion of possible pain processing issue (abnormal brain processing of pain ) how does that work and how does the brain process brain wrong for 15-20 years,wouldnt the epidural injection numb those nerves atleast for a short while. 15-20 years ago I never had radiating pain in my left leg and wasnt diagnosed with nerve impingement before. I would love for the pain to just disappear but i dont think thats going to happen, I’ve given it a long time to heal and it not happening. I think you was dead on with alot of the stuff you was stating
about why a feel the way I do and what the problem is. I would like to email a MRI to if possible to take a look a the L5-S1.
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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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