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#6263

Dear Dr. Corenman:

I am writing you in hopes that you may be able to direct me to what you consider the best potential non-fusion treatments (in your view) now or in the near-future for spondylolisthesis, stenosis & bulging/herniated disks in the lumbar spine. I am a patient with those issues and don’t believe fusion is the right course for me given my age (52) and activity level (highly active), but fusion is recommended by most surgeons I’ve spoken with. But what I read in NLM publications, fusion has iffy benefits over the long-term. I am feeling great trepidation as to my physical future that comprises such an important part of my life, health and my family’s. Any thoughts or direction would be very appreciated.

As I understand my diagnosis from MRI’s & x-ray evaluations, these are the problems I have in my lower back:

1. Degenerative Disc Disease: [L3/L4] [L4/L5] [L5/S1] Bulge/Herniations with moderate disk height loss
2. Spinal stenosis: [L3/L4] T [L4/L5] [L5/S1]
3. Foraminal Narrowing: [L4/L5] Abut [L5/S1] Abut [L3/L4] L [L4/L5] [L5/S1]
4. Facet Disease: [L3/L4] [L4/L5] [L5/S1] – L4/L5 noted as severe facet hypertrophy and L5/S1 noted as severe & extensive facet hypertrophy
5. Spondylolisthesis: L5/S1, with 9mm anterior displacement. That slip was 3mm 2 years ago on a prior MRI.

So, I guess you could say I’m one of the lucky ones in having the kitchen sink of issues. I am very healthy otherwise, but the pain, particularly the radicular symptoms, is becoming debilitating. I have done aggressive P/T for years (the problem has persisted over the last 9 years), and my P/T advisor said there is nothing further they can do, although I know there are always additional options that might assist (I’m looking into those now). I have tried chiropractors and active release therapy (ART) as well. I have had several facet cortisone injections over 2 years (1 out of 4 had a moderate pain reduction for 1.5-months, followed by a full return of symptoms). I had a diagnostic facet nerve block that made my mid-back feel somewhat better, but did nothing for the lower back & gluteal pain.

Friday May 18, I had an epidural injection. Pain moderated on Saturday for the day (down from 7/10 to 4/10 pain), but returned Sunday & Monday on the same pain cycle. It felt like the epidural just did not get down to the L5/S1 area, maybe because of stenosis and disk blockages, or maybe it just had no effect. At this time, the primary pain of concern is radicular, the 2-3/10 pain in my back is incidental and I can live with that. I had a followup block put in at L5/S1 yesterday. There was physical pain during the injections that ran down my butt & leg. I take that as a good sign in that it must have been into an area of impingement, and for at least today (Saturday), my pain is down to 3 from 7 or 8.

Several surgeons have recommended variations of thermal ablation, decompression, laminotomy, discetomy and fusion. Fusion is the most recommended component with the others. Because of problems at several disk levels, the fusion is recommended S1 – L3. My limited understanding from my readings is that this will incapacitate me relative to my active lifestyle, and most likely over the long term cause related problems in my thoracic region. In short, fusion does not present good enough clinical results over the long-term relative to my own likely longevity.

Any thoughts or direction would be very much appreciated. It seems the USA is a bit behind the rest of the world in back treatment options absent fusion. I am looking for a doctor here who might have different recommendations/options.

I have a copy of my x-ray & MRIs if that would be useful for your consideration.

Best regards, and thank you.

[Donald Corenman, MD, DC]

#6265

Let’s start from the beginning. Please read the section under “Treatments” – “How to describe symptoms” and begin by describing your history, symptoms, limitations and treatments in a chronological order.

The MRI and X-rays are very important to associate your symptoms with the pathology. The most significant finding you noted is the progressive isthmic slip at L5-S1 from 3mm to now 9mm over the last two years. The other levels involved in degenerative changes may or may not be involved symptomatically. There are tests that can reveal what their significance is.

You want to avoid fusion and that may be possible for all the levels but L5-S1. That lowest level has revealed instability (progressive slip over two years). If you do nothing, this slip is most likely is going to progress making any future surgical repair very difficult.

Please let me know specifically what and where your symptoms are and we can start to define what is causing your 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.

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#6266

I have had periodic back pain episodes dating back 20 years or more, they were often intense in lower back area, but short-lived (OK within a day or so of rest/stretching, etc.). About 9 years ago, my back started to stiffen considerably in the L3 – S1 zone, but P/T seems to have dealt with that pain to a reasonable level (now background 1 – 2/10 pain for that aspect).

The current sharp, stabbing & burning radiating pain is recent (last several months) and is more intense (7 to 8 out of 10 on the pain scale). That particular pain is relieved by sitting or flexing forward. Walking is difficult when the pain events are at their highest levels, running or anything more than that impossible.

The majority of the pain (~80%) seems related to the radiating symptoms down my glutes and hips, and the remainder is lower back pain.

Standing after sitting always increases the radiating pain, and usually I cannot walk until I stretch & try to get the back calmed down a bit. I am wearing an over-the-counter back brace that seems to help somewhat when walking & doing my P/T workouts. My lower back pain (20%) does not change much whether sitting or standing, but does decrease after P/T workouts, particularly stretching/core exercises. The radiating pain moderates as well, but to a much lesser degree and for less duration.

I sleep relatively pain-free with a pillow under my knees positioned on my back. I can also sleep on my sides just fine, but cannot sleep on my stomach without pain.

I have stopped all activities that cause increased pain. As I mentioned above, I can ride a bike still and do my P/T workouts, but that’s about all. Swinging a golf club softly often relieves some pain, but walking the course causes pain, so I’ve stopped that too. My regular activities when not pain limited include skiing (water & snow), snows boarding, snow skiing, snow & water kiting, mountain biking, running, tennis, golfing, hiking and other related outdoor activities.

My treatments have been P/T over the last 6 years, and injections over the last two. I have had 4 facet injections over 2 years, 1 of which moderated pain for 1.5-months, but the other 3 had no effect. I had two epidural injections over the last two weeks (1st put in around L3/L4, 2nd at L5/S1), each had pain benefit for a day or two, and the radiating pain has returned to its prior levels.

Thank you so much for the thoughts and advice!

[Donald Corenman, MD, DC]

#6267

Now the symptoms can be associated with the pathology. 80% of your pain is buttocks and “hips” (which I interpret to be posterior pelvis or thighs- am I correct?) and 20% is lower back. This means that most pain is going to be related to nerve root compression.

Standing and walking will significantly increase your pain and bending forward will give some relief. This means either foraminal stenosis or central stenosis (see website on either of these two diagnoses for further information).

The areas where this condition is noted by MRI are L3-S1. Because of multiple levels involved, diagnostic injections are called for to identify which levels are causing pain (see website under selective nerve root blocks and pain diary). If there is no instability at other levels and only the L5-S1 level is slipped, this level more likely is the pain generator. However, if other levels are slipped, greater care has to be taken to identify the pain generator.

If you can remember how the symptoms were affected in the first three hours of each injection (see pain diary on website), write these down as to not forget them. You will probably need more injections to more specifically identify the focal area of pain generation.

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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#6268

Many thanks Doctor! What I take from all this is that stabilization of S1/L5 & probably some associated decompression/discectomy are necessary in the near future after additional diagnostic testing to ensure we are solving the right problems.

In my readings, I notice that the EU & Asia are much more inclined, with good reported results, toward dynamic stabilization absent fusion, with the Dynesys system being widely applied. If you had any thoughts on that option, it would be much appreciated, as have been these other recommendations.

Again, many thanks. You see thousands of cases. We patients each see only one, and are quite concerned about our potential outcomes (as you clearly know).

[Donald Corenman, MD, DC]

#6269

Dynamic stabilization does not work. Europe does use it but the studies are poor and the biomechanics are deficient. I have revised many of these devices after failure.

The Dynasys system changes the center of rotation of the vertebra from the middle of the disc to the back of the facets. This causes facet wear and stress. The pedicle screws become loose and this bone-metal motion is also painful. Normal discs that are to be protected by the Dynasys system actually wear out faster.

Again, fusion works for the correct situation. Instability as demonstrated by the L5-S1 level is the perfect situation for fusion. The levels above may or may not need stabilization depending upon the MRI findings and abnormal motion based upon flexion/extension X-rays.

Every patient should have significant consideration and education. Even though I see thousands of patients, each one is taken care of like they were family.

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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