[Donald Corenman, MD, DC]

#9488

Bertolotti’s syndrome is generally not painful but I have seen two cases of pain (in about two hundred cases of this syndrome). I would not focus on this articulation as the central cause of your lower back pain.

This interspinous spacer is not a good idea, especially for you. This device causes kyphosis which is the exact opposite of what you need to compensate for your Scheuermann’s kyphosis. The Scheuermann’s thoracic kyphosis has to be compensated by increasing the lumbar spine lordosis to allow you to stand upright and balance your torso over your pelvis.

This spacer will throw you further forward and take away some of the compensatory mechanism that you now use to stand upright.

I understand your desire to gain some relief as lower back pain is miserable to live with. If you are going to do something about it, make sure you address the problem that causes the pain and do nothing that makes your condition worse.

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.

[massimo]

#9601

Hello Doctor Corenman,

I have had a number of spinal consults and it has taken some time to put things in perspective. Spinal instability at multiple levels has been indentified through a series of Dynamic X-RAYS including flexion and extension.

After being involved in a moderate rear end collision back in October 2011 my life has been a state of regression. I can’t deal with the daily pain anymore. I have decided to follow through with the posterior spinal fusion of T3 to L1 with the posterior osteotomy. Unfortunately the lumbar spine is comprimised at 4 levels in a multifactorial way. A three level ADR has also been advised for the lumbar spine as well as a one level ADR in the cervical spine.

It has not been an easy decision however with the progressive symptoms and unbearable pain I now welcome the last resort, surgery.

Thank You for your devotion to this forum and the support and guidance you give to all your patients and forum members.

Sincerely,
Massimo

.

[Donald Corenman, MD, DC]

#9621

A T3 to L1 fusion is a typical fusion for Scheuermann’s disorder. Good luck with that surgery. Please keep us informed regarding your progress after surgery for education of all the forum readers.

Be very careful regarding artificial disc replacements (ADRs) in the lumbar spine. I have written a section regarding this surgery on the website so you can get my take on them. I think that ADRs in the cervical spine can work in the right circumstances.

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.

[massimo]

#9885

Hello Doctor Corenman,
Thank You for directing me to the ADR information it was insightful.
Recently, I have had another spinal consult which has been informative. As previously mentioned , I have spinal instability at multiple levels of the lumbar spine. The spondylolisthesis and restrolisthesis at the affected levels is not vastly noted. The surgeon that I spoke to advised me before making any decisions an updated X-RAY Dynamic Study with flexion and extension views will have to be performed. He said that unfortunately, the original thoracic and lumbar flexion and extension views performed at my local Hospital were performed incorrectly. They were performed laying down on a X-RAY Table and not standing (weight bearing), therefore a true perspective of the degree of instability in those two spinal segments is inconclusive and therefore as the rest of the spinal segments. This may change the surgical outcome, I will have to wait until this study is correctly performed. The surgeon advised me that I would be a good candidate for multi-level implant by means of the Wallis Device. He informed me that this surgical procedure is reversible if in need. Unlike multi-level fusion I would still have some mobility in my lumbar spine and most importantly spinal stability. In additional neural foraminal space for the exiting nerve roots would increase. He also said that he would clean out the foraminal openings of entophytes and other debris.

I did ask for explanation as to how the interspinous device will affect the Scheuermann’s Kyphosis…

The surgeon informed me that the favourable approach would be addressing the lumbar spine first as the multi faceted issues are not going to get better and that in fact it will continue to regress if anything. I was also advised that the extensive thoracic spine surgery that was proposed could have very serious affects on the lumbar spine with instability, Bertolotti’s and the fairly heavy build up of Osteochondrosis throughout the posterior process levels of the lumbar spine. I was advised that if I was seriously contemplating the multi-level thoracic spine fixation it would definitely warrant reassuring that the lumbar spine would be accepting of the enormous load that would be transferred from an eleven vertebrae fusion with hardware. In addition if there was any undo stress on the kyphosis it could then be addressed subsequently with the surgery proposed initially.

My apologies, I have another quick question. Can multi-level spondylolisthesis and restrolisthesis cause dextroscoliosis?

With Sincere Appreciation
Massimo

With Sincere Appreciation
Massimo

[Donald Corenman, MD, DC]

#9898

Scheuermann’s kyphosis is an increase of the normal thoracic curve (20-40 degrees). The lumbar spine has to accomodate this increased kyphosis by increasing the lumbar lordosis (backwards curve) to balance the torso over the pelvis. Without this accomodation of the lumbar spine, you would be thrown off forward when walking.

The Wallis device (like the X-Stop or Coflex devices) is an interpositional device that sits between the spinous processes and flexes these segments (bends them forward). By definition, this flexion reduces the lumbar lordosis and reduces your ability to accomodate the increased thoracic curve.

Generally, I am not a fan of these interpositional devices as the problem they attempt to solve (stenosis of the central canal, lateral recess or foramen) can be solved by a surgical decompression of these areas without the need to flex the two vertebra and the attendent problems that this can cause.

Also, these interpositional devices can and do erode into the spinous processes and become non-functional after some period of time.

The thoracic Scheuermann’s surgery will reduce the need for the lumbar spine to extend to accomodate the increased thoracic kyphosis. I cannot comment on the effects of instability in the lumbar spine after the thoracic surgery without a thorough history, physical examination and evaluation of your images.

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.

[massimo]

#11340

Hello Doctor Corenman,

During my last communications via your forum I was pursuing different options as to surgical intervention in regards to my spine. I have had to put my investigations on hold since having a heart attack on April 13, 2014. An emergency stint procedure had to be performed for a 100% blocked Coronary Artery. Sadly, I have come to find out that I had high lipids/cholesterol for over 20 years and unfortunately I was never aware and obviously never treated for. I have an intertwined question for you…
“Can cardiovascular conditions such as mine be contributed in part of spinal diseases such as A.S, D.I.S.H and Scheuermann’s Disease” ?

I have spoken to an internist and he could not elaborate as spines and diseases within the spine are simply not his specialty. I have come across some medical literature in the research of the correlation of heart disease and spinal arthropathies and I was just wondering if you had some insight to this connection.

Secondly but most paramount, my spine. I have hit additional crossroads in my research for answers and a possible partial resolution. Living in Ontario, Canada I have spent some time lately obtaining updated diagnostic information and surgical inquiries. I have come to understand the complexity of my spine by means beyond borders. I have had the privilege to have spoken to numerous orthopaedic and neurosurgeons from various countries around the world which have evaluated my diagnostic imaging. I realize that there are no simple solutions to my spinal demise.

Unfortunately there has been no improvement in my vertebral spine pain and upper and lower limb radiculopathy / pain and loss of mobility. The frequency of urinary retentions and dribbling has increased over the last two to three years now. In fact, there has been consistent regression in my overall physical status and frankly, the widespread pain has become somewhat inhumane. Pharmaceuticals have proven to be inadequate and therapies such as chiropractic and physiotherapy only provide minimal relief at best and at times make things worse. I have become very cautious when I walk because of leg radiculopathy / pain and weakness but unfortunately my walking has been severely compromised since the fall of 2011. After experiencing leg weakness and falling for over three years I have fragmented a bone in my foot in 2012 and I fractured my ankle in May of 2013. It’s the little things in life that we take for granted but how I miss the ability to be who I was…

I have included updated diagnostic reports for your viewing. This leads me to my second question…
Being 45 years of age I have been familiarized with unfounded Canadian labels and diagnosis but what is really happening to my spine?

I have recently spoken with an American neurosurgeon that shared his recommendation of multilevel – segmented spinal surgeries. The uncommon twist of his perspective which varies from past opinion and recommendations is that he would also address my spine with stem cell therapies.

Thank you as always Doctor Corenman,

Massimo

MASSIMO
CERVICAL SPINE SECOND OPINION
CONDENSED REPORTS
MRI AND X-RAY

There is straightening of the spine with loss of normal cervical lordosis seen due to paravertebral muscle spasm. There is evidence of grade one retrololisthesis of C2 over C3 and minor retrololisthesis of C5 over C6. Multilevel dehydration and desiccation is seen. The nuchal ligament is hypertrophic at the C6 and C7 levels.

At C2-C3 level, minimal bulging indents the ventral thecal sac. Canal and foramen remain patent.

At C3-C4 level, central shallow herniated disc measuring 5mm in transverse and 2.5mm in AP dimension, indents the ventral thecal sac. There is a superimposed bulge with annular laxity with bilateral uncovertebral joint hypertrophy, this is marginally worse on the left side resulting in mild left foraminal stenosis.

At C4-C5 level, central herniated disc measuring 7mm in transverse and 2.5mm in AP dimension, indents the ventral thecal sac. There is a superimposed bulge. Canal and foramen remain patent. There is bilateral uncovertebral joint hypertrophy.

At C5-C6 level, there is a large herniated disc / osteophyte noted, measuring 12mm in transverse and 3mm in AP dimension in contact with the spinal cord. There is mild canal stenosis (AP dimension is 9.5mm). There is some lateralization to the left side and likely in contact with the left exiting C6 nerve root. There is mild to moderate narrowing of the left lateral recess consequent compression of the left descending C7 nerve root can be expected. Bilateral uncovertebral joint hypertrophy is present.

At C6-C7 level, a disc bulge is seen indenting the ventral thecal sac. Canal and foramen remain patent. The nuchal ligament at the C6 and C7 vertebral level is hypertrophic.

At C7-T1 level, there is no bulge or herniation. Canal and foramen remain patent. There is a small 3.5mm per neural cyst seen in relation to the exiting right C8 nerve.

MASSIMO
THORACIC SPINE SECOND OPINION
CONDENSED REPORTS
MRI AND X-RAY

The vertebral bodies from T6 to T11 show elongation of the antero-posterior dimension. Note is made of mild compression fracture deformities of T7 and T8 vertebral bodies. Schmorl’s Nodes are seen at multiple thoracic levels including T6-T7, T7-T8, T8-T9, T9-T10, T10-T11 and T11-T12 levels representing endplate micro fractures. There is mild disc desiccation seen at the T2-T3, T3-T4, T9-T10 and T10-T11 levels. There is moderate disc desiccation from T4-T5 to T8-T9 levels. Mild reduction of disc height is seen from T6-T7 to T10-T11 levels. Type II modic endplate changes are seen at the T11-T12 level. There is evidence of mild dextroscoliosis at the apex, approximately at the T9-T10 level. There is moderate degree of anterolateral osteophytosis seen worse on the right side caudal to the T3-T4 level.

At T1-T2 level, there is annular disc laxity causing mild left foraminal stenosis. Minimal hypersclerosis is seen with minimal anterior and posterior marginal osteophytosis.

At T2-T3 level, minimal hypersclerosis is seen with minimal anterior and posterior marginal osteophytosis. No canal or foraminal stenosis.

At T3-T4 level, minimal hypersclerosis is seen with minimal anterior and posterior marginal osteophytosis.
No canal or foraminal stenosis.

At T4-T5 level, minimal hypersclerosis is seen with minimal anterior and posterior marginal osteophytosis.
No canal or foraminal stenosis.

At T5-T6 level, minimal disc bulge indents the ventral thecal sac. Canal and foramen remain patent. Mild endplate sclerosis is seen. There is mild facet arthropathy. There is mild to moderate anterior and posterior marginal osteophytosis.

At T6-T7 level, minimal disc bulge indents the ventral thecal sac. Canal and foramen remain patent. There is moderate endplate sclerosis. There is mild facet arthropathy. There is mild moderate anterior and posterior marginal osteophytosis. There is mild costo-transverse joint arthropathy seen.

AT T7-T8 level, minimal disc bulge indents the ventral thecal sac. Canal and foramen remain patent. There is moderate endplate sclerosis. There is mild facet arthropathy. There is moderate anterior and posterior marginal osteophytosis. There is mild costo-transverse joint arthropathy seen.

At T8-T9 level, central herniated disc noted measuring 6mm in transverse and 2.5mm in AP dimension producing mass effect on the spinal cord and demonstrates spinal cord flattening and borderline canal stenosis. Mild loss of joint disc space is seen. There is moderate endplate sclerosis. There is moderate anterior and posterior marginal osteophytosis. There is mild facet arthropathy. There is mild costo-transverse joint arthropathy seen.

At T9-T10 level, minimal disc bulge indents the ventral thecal sac. Canal and foramen remain patent. There is moderate endplate sclerosis. There is mild facet arthropathy. There is moderate anterior and posterior marginal osteophytosis. There is mild facet arthropathy. There is mild costo-transverse joint arthropathy seen.

At T10-T11 level, There is moderate endplate sclerosis. There is mild to moderate anterior and posterior marginal osteophytosis. There is mild facet arthropathy. There is mild costo-transverse joint arthropathy seen.

At T11-T12 level, shallow herniated disc indents the ventral thecal sac. There is moderate endplate sclerosis. There is mild to moderate facet arthropathy seen causing mild to moderate right and mild left foraminal stenosis with the disc / osteophyte seen in contact with the exiting right T11 nerve root.

OTHER DIAGNOSIS IN PARTOF THE THORACIC SPINE[/b]

1) SCHEUERMANN’S DISEASE
Diagnosed March 14, 2013 Dr. Stephen Lewis (Toronto Western Hospital)

2) DISH (DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS)
Diagnosed May 7, 2002 Dr. Angela Mailis (Toronto Western Hospital)

3) A.S (ANKYLOSING SPONDYLITIS)
Diagnosed December 17, 1990 Dr. Ian Sutherland
(The Medical Centre, Peterborough) HLA-B27 Positive

MASSIMO
LUMBAR SPINE SECOND OPINION
CONDENSED REPORTS
MRI AND X-RAY

There is disc desiccation from L2-L3 to L5-S1. Mild reduction of disc height is seen from L2-L3 to L5-S1, most marked at the L5-S1 level. Shallow schmorl’s nodes are noted from L2-L3 to L5-S1 levels. Dextroscoliosis is noted with the apex at approximately at the L4-L5 level. Note is made of minimal grade one retrololisthesis of L1 over L2. Grade one retrololisthesis of L2 over L3 is not appreciated measuring 4mm. There is grade one retrololisthesis of L4 over L5. Multi-level spondylolisthesis with evidence of ligament instability. Mild degenerative changes at both sacroiliac joints. Note is made of L5 segments sacralised to the ala of the sacrum.

At the L2-L3 level, there is an annular disc bulge seen. There is a superimposed far right paracentral herniated disc with associated annular tear. There is mild to moderate right and mild left foraminal stenosis with disc / osteophyte seen in contact with the exiting right L2 nerve. Canal is patent. Moderate endplate sclerosis is present. There is mild to moderate facet arthropathy / ligament flavum hypertrophy noted. There is moderate anterior and posterior marginal osteophytosis in conjunction with spondylolisthesis and spurring.

At L3-L4 level, bilobed annular disc bulge is seen with bilateral intraforamen extension. There is a shallow left and right parietal disc herniation present. There is mild to moderate foraminal stenosis with disc / osteophyte seen in contact with both exiting L3 nerves. There is no canal stenosis but the disc is also in contact with both descending L4 nerves. There is mild to moderate endplate sclerosis present. There is moderate anterior and posterior marginal osteophytosis. There is moderate facet arthropathy / ligament flavum hypertrophy seen.

At L4-L5 level, annular tear is visible. There is a central herniated disc measuring 10mm in transverse and 2.5 mm in AP dimension that indents the ventral thecal sac. The canal is patent. There is a superimposed bulge with bilateral foraminal stenosis and mild left lateral stenosis. Corresponding compression of the bilateral L4 exiting nerve can be expected. There is mild endplate sclerosis with minimal anterior and posterior marginal osteophytosis. There is moderate facet arthropathy / ligament flavum hypertrophy.

At L5-S1 level, diffuse disc bulge is noted. There is a superimposed left paracentral disc / osteophyte herniation noted. There is mild to moderate bilateral foraminal stenosis and left lateral recess stenosis. Corresponding compression of the bilateral exiting L5 nerve and left traversing S1 nerve can be expected. The canal is patent. Mild endplate sclerosis is noted. There is mild to moderate facet arthropathy / ligament flavum hypertrophy.

OTHER DIAGNOSIS IN PART OF THE LUMBAR SPINE

1) BILATERAL SACRALIZATION OF THE L5 TRANSVERSE PROCESS
Diagnosed August 4, 1998 Dr. w. Weiser (Radiologist)
Diagnosed August 6, 2013 Dr. Michael Yuz (Radiologist)

2) SPINA BIFIDA OCCULTA
Diagnosed May 7, 2002
Dr. Angela Mailis (Toronto Western Hospital)

3) DYSPLASTIC (FALSE ORIENTATION) OF THE RIGHT SUPERIOR ARTICULAR
PROCESS OF THE SACRUM
Visulaized in 3D CT Study L-Spine June 17, 2011

4) BILATERAL SACROILIAC DISEASE
Diagnosed September 27, 2013 Dr. William Smith (AIMIS SPINE)

5) OSTEOCHONDROSIS OF THE FACETS AND SPINOUS PROCESS
Visualized 3D CT L-Spine June 17, 2011

6) MILD SCOLIOSIS
Diagnosed March 1, 2013 Dr. Frank Marrocco (Radiologist)
Diagnosed March 10, 2013 Dr. Michael Yuz (Radiologist)

7) BAASTRUP’S DISEASE
Visualized 3D CT L-Spine June 17, 2011

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