Non-fusion of cervical spine

Tagged: cervical pseudoarthrosis (lack of fusion)

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Jellyhall
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September 18, 2019 at 7:59 am

Post count: 91

#31118

I have problems throughout my spine. I had an ACDF of C3/4/5 done 7 years ago. I also had a lumbar laminectomy and fusion of L4/5 done 9 and a half years ago. I now have adjacent disc syndrome either side of both my cervical and lumbar fusions.

I am awaiting radiofrequency ablation of nerves in my lumbar spine in the hope that I will get longer lasting pain relief after facet joint injections helped me.

My cervical and thoracic spine are still concerning and I am being sent for 3-Tesla MRI scans of them both, ‘counting up from L5/S1’.

At my last appointment, and the first with the consultant himself, he shocked me by saying that I might need more surgery on my neck. Three of his Fellows hadn’t noticed this. He has sent me for a cervical CT scan to see if I am fused or not. Surely I would have known before now if I had not fused. Is it possible for an already fused level to suffer a broken fusion?

I have looked at some flexion / extension cervical x-rays that were done a year ago, and I think I can see why the surgeon is concerned. There appears to be a dark line / gap between the edge of the Titanium CeSpace implant used and the edge of the vertebra on the lower implant. If it is discovered that this is not fused, will another surgery be the only solution? Would this likely be anterior or posterior?
My follow up appointment isn’t until February next year, which seems a very long time to wait for an answer! (I am in the UK where long waits are very common)

I would be very grateful to hear what you think Dr Corenman.

Donald Corenman, MD, DC
Moderator

September 19, 2019 at 8:22 pm

Post count: 8660

#31123

You certainly could have a pseudoarthrosis of your C4-5 level as you note “appears to be a dark line / gap between the edge of the Titanium CeSpace implant used and the edge of the vertebra on the lower implant”.

Is another surgery the only option? Well, this lack of fusion will not heal by itself after so may years of distance between surgery and now. This condition is generally not dangerous however so you could live with it as long as you can tolerate the pain. The options to fix it are to go anterior again, remove the old cage and perform a new fusion (normally with iliac crest bone graft which should be used for all pseudoarthroses in my opinion) or go posteriorly and perform a fusion from the back. The fusion in back takes longer to heal but is still a reasonable option. If you have a need for other levels to be included, I would advise an anterior approach.

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.

Jellyhall
Participant

September 23, 2019 at 10:19 am

Post count: 91

#31142

Thank you Dr Corenman for your reply.

The 2 levels of C5/6 and C6/7 are also very degenerated with the disc practically completely gone and there is foraminal stenosis, which is why I am assuming that I have pain in both hands and arms.

I asked the neurosurgeon who did my ACDF 7 years ago, about not using any bone graft, plate and screws or collar. He explained that he and other neurosurgeons at the same hospital had been using the ‘stand alone titanium CeSpace implants’ for over a decade and they were successful. He described one of his colleagues who needed to remove one just 2 weeks after the ACDF surgery due to incorrect placement, and it was in so tightly that it was necessary to drill it out.
This now worries me as although the upper level of the implant appears to not be attached, the lower level does look like it is fused to the vertebra.
He also explained that he was doing an anterior surgery because he may need to do another surgery on the two levels below in the future, and it was difficult to do a repeat fusion surgery using anterior access after a posterior surgery had been done. I do have more pain now than before my first neck surgery, both in the neck and in my arms and hands.

Donald Corenman, MD, DC
Moderator

September 23, 2019 at 12:15 pm

Post count: 8660

#31146

It very well may be true that you need to address the C5-7 levels as well as the failed C4-5 level. I am not sure why this surgeon is reluctant to remove this titanium cage but maybe he has little experience with removals or has had a bad experience in the past. I am unclear why “it was difficult to do a repeat fusion surgery using anterior access after a posterior surgery had been done”. It generally is not a problem to repeat an anterior approach and a posterior fusion does not generally affect a repeat anterior approach.

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.

Jellyhall
Participant

October 1, 2019 at 12:32 pm

Post count: 91

#31224

I have now had a CT scan to see if my lower level of ACDF is fused or not. I am awaiting flexion/extension x-rays on my neck and a new MRI scan in 3 Tesla scanner of my neck and thoracic spine. I hope that I will hear if I am fused or not before my February appointment. It is a long time to wait with that uncertainty.

My last flexion/extension cervical x-ray stated that there is a grade 1 spondylolisthesis that moves slightly on the flexion x-ray compared with the extension one. Would you think that this also needs to be dealt with if another surgery is done?

I am also looking into postmenaupausal women having a higher chance of pseudoarthrosis due to lack of estrogen. I am now 64. If I do need another surgery to deal with this, do you think that it would be worth me taking HRT to attempt to improve my chances of fusing? I am also wondering if having a plate would help.

The surgeon who did my ACDF wasn’t reluctant to remove a titanium cage. Our discussion was before my surgery when I had asked about not having any bonegraft, plate and screws or collar. He was giving me evidence that a stand alone titanium cage would fuse.

I am under another surgeon in London for ongoing spine issues. These are also in my lumbar and thoracic spine. I had thought that my cervical spine was fine and wasn’t going to need another surgery because I had been told that there was spinal fluid flowing around the cord, so no more surgery was needed. This latest surgeon has told me that I do have foraminal stenosis.

I am very interested to hear your opinion about taking HRT and if you think C2/3 would need attention.
Thank you for your help Dr Corenman.

Jellyhall
Participant

October 4, 2019 at 11:49 am

Post count: 91

#31233

I have just read my post above and realised that I didn’t tell you which level the grade 1 spondylolisthesis that moves slightly was at. It is at C2/3, the level above my top fused level.
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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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