One in a Million? T9-T10 Symptomatic Disc Herniation

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Donald Corenman, MD, DC
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October 17, 2011 at 2:08 am

Post count: 8660

#5004

Please forward your images to my office. Call (970) 476-1100 and ask for one of my nurses.

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

October 26, 2011 at 11:14 am

Post count: 34

#5044

Dear Dr. Corenman:

WOW. Thanks.

I will ring tomorrow about sending my films along. If it’s a re-herniation, maybe we can write it up — a first for the literature ;) More important to me though, is to understand this and not have a recurrence, be it the second, third or whatever. I suppose I am encouraged that there is less material to herniate now, less jelly at least. The idea of the tough stuff herniating is a bit scary though. While not strictly indicated, I’m keen to get this re-imaged.

The thoracic spine is especially stable, right? So will I have to worry as much about narrowing of the vertebral space and vertebral displacement with the loss of disc material?

Cheers

hart
Member

November 9, 2011 at 1:25 pm

Post count: 34

#5089

Hi Dr. Corenman:

I have yet to get my films to you. Sorry! But I now have another film. I ran home and looked at the study and I didn’t see the protrusion. The black blob was gone! Every level looked the same — that’s about my level of expertise ;)

I had the study today and we heard from the radiologist tonight. A completely normal T-spine MRI at 10 months! He and his colleagues (one of them the radiologist who read the old film back in January) have never seen or heard of such a “disappearance” in the T-spine. They have seen such findings in L-spine herniations on occasion. After taking a look at the old MRI, they returned to today’s study and decided just maybe there was a little something to be seen. Essentially normal. I await written report.

I am not 100% but I guess my MRI is! Of course, we know it is still a crappy disc! WOW…normal MRI…is this an especially good thing or just an interesting finding?

I will send you the films! Thank you for your enlightening discussion of etiology. You are the only person who has been willing (?able) to discuss possible explanations for this “injury”.

Cheers,
Hart

PS. So does this make me like one in a BILLION? Ha. I do realize that the “one in a million” number has been thrown into question and that symptomatic T-spine herniations are probably not as rare as once thought!

hart
Member

November 12, 2011 at 2:40 am

Post count: 34

#5095

Got the report…

IMPRESSION:

1. THE PRIOR EXAM OF 01/04/11 SHOWED A LARGE FAR RIGHT LATERAL DISC EXTRUSION WITH CEPHALAD MIGRATION OF THE EXTRUDED DISC. THIS AREA HAS SHOWN REMARKABLE IMPROVEMENT SINCE THE LAST EXAM WITH NOW ONLY A 3MM RIGHT LATERAL PROTRUSION AND NO DEFINED NERVE ROOT COMPRESSION.

2. MILD MULTILEVEL DEGENERATIVE DISC DISEASE WITH ENDPLATE SPONDYLOSIS AND SMALL SCHMORL NODE DEFECTS T7-8 THROUGH T10-11.

3. MINOR 1MM POSTERIOR ANULAR BULGING T8-9, T10-11 AND T11-12

4. STABLE APPEARANCE OF A SMALL BENIGN SIGNAL ABNORMALITY WITHIN THE ANTERIOR T9 VERTEBRAL BODY.

Donald Corenman, MD, DC
Moderator

November 12, 2011 at 8:21 pm

Post count: 8660

#5097

The report that the new MRI is now “normal” is suspicious. The previous report noted not only the large extruded fragment but multiple areas with “MINOR 1MM POSTERIOR ANULAR BULGING T8-9, T10-11 AND T11-12”. These do not just “go away” but if the MRI was performed in such a manner that the image resolution was poor or the machine was of low quality, the findings can be different.

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

November 13, 2011 at 3:48 am

Post count: 34

#5101

Hi Dr. Corenman:

Sorry about the confusion! That is the new report. The machine and one of the radiologists were the same in both studies. The MRI was performed on a GE High Field 1.5 Tesla Signa Infinity Excite. I read that 3T is out there on the street but the machine in question seems pretty typical. I have sussed out the radiologists involved. I feel like I stumbled on some pretty good ones. I deliberately went back to the same machine and asked for the same neuroradiologist, a young doctor with an impressive CV. I got a different radiologist this time, an older guy without the “neuro” in “radiologist”, a former flight surgeon who served as director of the radiology residency program at Presbyterian/Saint Luke’s Medical Center in Denver for a decade. He did consult the radiologist who read the initial film. They found the change remarkable. The radiologists received detailed “orders” for both these studies. In the event that the study was inadequate for whatever reason, wouldn’t the radiologist report it as such and recommend further imaging?

To review:

04 JAN 2011 — the initial study reported by the young neuroradiologist

IMPRESSION: 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

Reported elsewhere: “A focal T10 inferior endplate defect is compatible with a Schmorl’s node as well as at T12 superior endplate.” “Remaining thoracic levels demonstrate no significant disc herniation or central canal stenosis.”

08 NOV 2011 — the follow up study reported by the older radiologist who, BTW, reports more Schmorl’s nodes than the first radiologist in addition to posterior bulging in the lower levels of the T-spine.

IMPRESSION:
1. THE PRIOR EXAM OF JAN/04/11 SHOWED A LARGE FAR RIGHT LATERAL DISC EXTRUSION WITH CEPHALAD MIGRATION OF THE EXTRUDED DISC. THIS AREA HAS SHOWN REMARKABLE IMPROVEMENT SINCE THE LAST EXAM WITH NOW ONLY A 3MM RIGHT LATERAL PROTRUSION AND NO DEFINED NERVE ROOT COMPRESSION.

2. MILD MULTILEVEL DEGENERATIVE DISC DISEASE WITH ENDPLATE SPONDYLOSIS AND SMALL SCHMORL NODE DEFECTS T7-8 THROUGH T10-11.

3. MINOR 1MM POSTERIOR ANULAR BULGING T8-9, T10-11 AND T11-12

4. STABLE APPEARANCE OF A SMALL BENIGN SIGNAL ABNORMALITY WITHIN THE ANTERIOR T9 VERTEBRAL BODY.

Elsewhere in the report: “Discs: Moderate disc desiccation and mild degenerative thinning multiple interspaces to include T7-8 through T10-11. This is unchanged in appearance.”

So “normal” was my doing! It is not REALLY normal. But if we were to round up healthy more or less normal 40 somethings on the street who never complained of back pain, could we find such? If degenerative disease is normal aging as some argue, after a certain age, a normal MRI would not be possible. So what exactly is a normal MRI at age 45 or 55 or 65?

1mm posterior bulges? I have watched your videos on MRI which are very good. And looked at some normal MRIs. Discs look a bit bulge-y all stacked up between the vertebrae, to this casual observer. Those 1mm bulges were not reported on the previous film but the radiologist who read the followup film points out that they are unchanged from the previous film. This suggests to me that they are on the threshold of reportable findings.

Yesterday, Friday PM, I left a message with Diana in your office with my details.

Cheers,
Hart
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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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