One in a Million? T9-T10 Symptomatic Disc Herniation

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hart
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September 25, 2011 at 9:30 am

Post count: 34

#4930

Dr. Corenman:

Sorry! My last post was very confusing!! I had misread something that you had made quite clear earlier. I realize that the jelly is not going back in the donut :)

A question that has been bothering me. I assume any scar tissue is not as strong as the original annulus. However, is there not less pressure exerted by the nucleus pulposis once it has lost volume?

More: In the medium term, can a detached fragment of the nucleus pulposis move about and cause trouble? Are these lesions considered more or less “stable” after some period of time? If so, how long generally speaking? Is the decrease in space between the ninth and tenth vertebrae likely to be a problem going forward? I realize there are no hard fast answers!

Another concern. This is my first disc herniation. Should I be especially concerned about getting disc herniations in the anatomically more vulnerable segments of the spine? Can one just write something like this off as a “fluke”?

Do you think there is enough force here to herniate a thoracic disc http://www.sinheeflowyoga.com/photo%20gallery/images/SIDE%20CROW.jpg ? I have a sneaking suspicion that this is how I did it. I felt something sort of “funny” but not pain. After some days or weeks, the pain became intolerable. All a bit insidious.

Thank you so much for addressing my questions. While it confirms much of what I have found in my research, it is very helpful to hear it here!

This is a great site! I love the motto! I had figured the best way to avoid spine surgery was to avoid spine surgeons. I am reconsidering :) I am going to order the book.

Cheers

Donald Corenman, MD, DC
Moderator

September 26, 2011 at 1:28 am

Post count: 8660

#4934

You are very intuitive. You make a great point that the scar that covers the annular tear is not as strong as the original collagen tissue that had torn. You are also correct that the pressure drop in the nucleus reduces the stress on the torn annulus.

Interesting that there are no case reports of recurrent thoracic disc herniations that I know of in the literature. There would be no recurrent hernations after surgery as surgery is designed to remove the herniation and fuse the level. The recurrence rate for lumbar disc hernations in an active population is about 10%.

A sequestered fragment (one not attached to the tear of the disc) can migrate but normally will migrate out of the canal and usually not cause further problems.

The chance of another disc herniation is limited. If you have Scheuermann’s disease (see website), you do have a higher chance of a herniation at another site, but still that chance is small. The positions of yoga you have sent by itself should not cause a herniation. However, if you already had a complete tear and load the disc in that manner, the herniation could occur.

There are some spine surgeons that think “If I have a hammer, the world looks like a nail” and everything is a surgical answer. I would like to think these individuals are rare. The surgeon should be the best person to determine if surgery is right for you. Many spine surgeons are also great diagnosticians and will discuss with you your options and should not push surgery unless it really is indicated or you are well informed of your options.

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.

hart
Member

September 26, 2011 at 4:25 am

Post count: 34

#4938

G’day Dr. Corenman:

Ha ha. I suppose the hammer and nail analogy applies to all fields of surgery. Spine surgeons seem to be enjoying the limelight lately. Don’t worry, WSJ will tire and move on.

No Scheuermann disease. I am told I lack even normal kyphotic curvature. Is there an eponym for this? I do have bothersome SI joints. Back in Australia, I asked my GP for a plain film of the pelvis and there was no sign of Ankylosing Spondylitis. Family history of AS and psoriatic arthritis. You can chase rheumatology forever but what good does it do. Like a dog chasing its tail. (If you can’t qualify a patient to a clinical trial of toxic agents, should you be giving the drugs?)

It is unsettling to have an injury that is not that easy to do and have no clue how you did it.

This may be a re-herniation for all I know. There is another finding. Perhaps some suggestion of an older lesion? I don’t have the report in digitized form so I will type it in…

“Findings: There is probably focal fat versus hemangioma of the T9 vertebral body. A focal T10 inferior endplate defect is compatible with a Schmorl’s node as at T12 superior endplate….”

Do you make anything of that? I looked up Schmorl’s node and I have concluded that they don’t form over two weeks (the period between my acute presentation and the MRI).

Epidurals: I am 9 months post acute presentation. Radicular pain resolved after a about 3 months. I had no back pain at the time of presentation, only maddening radicular pain at the costal margin. Now I have a sore thoracic spine. I do not like to do twisting exercises — PNF with cables. Even at minimal resistance. I can bear the pain of the exercises — it is just uncomfortable. After I get home, I start to hurt and can’t sleep well. Is an epidural warranted to help me comply with my exercises?

Cheers

Donald Corenman, MD, DC
Moderator

September 26, 2011 at 1:43 pm

Post count: 8660

#4939

Your Schmorl’s nodes go along with soft endplates when you were young. This can be a form of Scheuermann’s disorder associated with degenerative disc disease in the thoracic spine which has a higher chance of herniation. Classic Scheuermann’s has wedging of vertebra and deformity but there is a variant that only has endplate changes without deformity. It is what it is- so don’t think too long and hard about it.

I still think at your point that epidurals can be effective. The success rate is not 100% but I believe relief can be gained in about 60-70% of patients. The question is how long the relief may last. It may be 3 weeks or 9 months. The pain level may drop by some percentage also permanently.

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.

hart
Member

September 27, 2011 at 3:52 am

Post count: 34

#4944

Thanks Dr. Corenman!

I had not considered Scheuermann’s disease! I was familiar with the kyphotic presentation. Very interesting. I am reading up on it. Characteristic deformity aside, all pretty wishy washy. Rheumatology?

I checked out some of the other threads here. You are very good at piecing information together!

Cheers

hart
Member

September 27, 2011 at 7:13 am

Post count: 34

#4945

Dear Dr. Corenman:

OK, this question was coming!

Again: “T9-T10 RIGHT SUBARTICULAR ZONE LARGE DISC EXTRUSION EXTENDING 4.7 MM POSTERIORLY AND 10 MM SUPERIORLY WITH RIGHT LATERAL RECESS STENOSIS AND MASS EFFECT ON THE EXITING RIGHT T9 NERVE”

“Findings: There is probably focal fat versus hemangioma of the T9 vertebral body. A focal T10 inferior endplate defect is compatible with a Schmorl’s node as at T12 superior endplate….”

Do you think the radiologist is saying that there are Schmorl’s nodes at both T10 and T12? (The rest of the finding were just statements of the normal.) If so: I have a herniation of the T9-T10 disc (?terminology) and a Schmorl’s node at T10. Does the presence of a Schmorl’s node at T12 suggest a susceptible disc at T11-T12? [Imaging (or just select images) is available if there is a mechanism to present it.]

Do you know what “focal fat versus hemangioma” means in the above findings? I interpret it (with VERY minimal experience) to mean “old” or possibly “normal”. (BTW: I effectively ordered this test in pain and amidst the xmas holidays and chose to forgo gadolinium, thinking “what’s next?”)

While probably not strictly indicated, I’m keen to get a followup scan. Will gadolinium add anything in this context? I realize reactions are rare but so are T-spine herniations.

Cheers
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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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