One in a Million? T9-T10 Symptomatic Disc Herniation

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hart
Member

November 11, 2012 at 7:13 am

Post count: 34

#7370

G’day Dr. Corenman:

Following my injury, the 10th rib on the right side started “poking out” and getting in the way. As I have regained strength over the last year, this has become less of a nuisance. Recently, I have started to go to yoga class again. I am getting “pinched” with certain movements.

I made this video of my dancing rib a month or so after my injury when the problem became apparent.

ht tp://

(There are 3 spaces in the url that must be deleted.)

Is it clear what muscles are involved? Can you make any specific suggestions for strengthening these muscles? (There is much more bulk now than in the video!)

Cheers,
Hart

Donald Corenman, MD, DC
Moderator

November 12, 2012 at 6:18 am

Post count: 8660

#7377

You have a floating right rib that is more elongated than normal and it “catches” with lateral bending. I cannot tell if this rib was fractured and now free floating or if it is a congenital variant. It might be uncomfortable and an annoyance but appears not to be dangerous.

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 12, 2012 at 7:53 am

Post count: 34

#7379

Thank you for having a look. This floating rib became apparent 4-6 weeks after presentation of disc herniation at T9-T10. (I stayed very still for the first six weeks following presentation!)

I have read up on costochondral separation of the false ribs. I have come to the conclusion that such an injury would take some doing…require substantial force. I suspect the tenth rib on the left is also a floating rib…I am fairly certain I can palpate the end of it as well…it is nicely buried though. I am convinced that I have floating tenth ribs on both sides which I have read is a normal variant. (I am not Japanese, btw.) Rib films and MRI of the abdomen (having looked at these, there must be more useful views!) were ordered by an internist. She didn’t have a clue what that was.I stayed pretty quiet though I had a pretty good idea even if I didn’t know how it got there! I refused contrast for the MRI, figuring it wasn’t indicated. I was given an oil filled marker to place over the “lump”. Radiology was essentially negative. (I think there was some edema reported in the area of the marker.) I find this puzzling given the defect in the surface anatomy.

Incidentally, I promise, I will make copies of all imaging and get it off to you. I am procrastinating. It has occurred to me that it is inconsiderate not to supply the films! I keep telling myself I will make it to Colorado soon and try to get an appointment!

That rib did not poke out like that before I acutely presented with this disc herniation! I am ABSOLUTELY certain of that!! Is it possible that I have muscle weakness as a result of previous T9 nerve root compression? (An MRI 8 months post presentation showed no nerve root compression and marked decrease in disc protrusion.) I am trying to figure out which muscles are involved in keeping that rib out of the way and how I can strengthen them. I have been told T9 has no motor supply. Does T9 have a motor supply? And if so, what does this nerve supply?

I suspect there is some irritation of the intercostal nerve. At first, I attributed this neuropathic discomfort to the T9 spinal nerve but quickly figured out that different motions were involved.

I any case, this is much improved just as you predicted. As I mentioned, the video is old and I don’t think I can make it do that anymore! Cutting it off, as some suggested, would have been a VERY bad idea!

I am wondering whether floating 10th ribs made it easier for me to herniate at T9-T10. Note: this is my first such herniation. (There is an incidental 1mm herniation at C5-C6 with the typical degenerative changes. I had impact in flexion to the C-spine with a C7 vertebral body fracture a couple of decades ago.) X-ray of the L spine are completely normal.

Hart

Donald Corenman, MD, DC
Moderator

November 12, 2012 at 8:02 pm

Post count: 8660

#7382

It is highly unlikely that this floating rib is the result of a radiculopathy. Motor weakness of that myotome would have also consisted of severe pain along that dermatome and residual numbness along that rib distribution. More likely than not, this rib is the result of both developmental propensity along with an injury (even though you are not Japanese).

Floating ribs are not related to an increased chance of disc herniation.

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 12, 2012 at 10:44 pm

Post count: 34

#7383

I HAD severe pain and numbness along that dermatome — on the front side of the body. There still seems to be some numbness although I am accustomed to it after all this time. I haven’t seen anyone interested in mapping out the numbness. (5 years previously, I had had a several month episode of a tuning fork sensation in the same distribution. No imaging was done.) In fact, I had NO back pain acutely! ONLY radicular pain of insidious onset. Several months into my rehabilitation, I developed a sore thoracic spine.

TODAY, I will FedEx the radiology to you. I do apologize for not getting on it MUCH earlier. In the meantime, I’ll repost the MRI “Impressions”:

January 2011:
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
(There was NO back pain at this time, only TERRIBLE front pain! I knew it was nerve root impingement.)

November 2011:
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.

I accept the idea that I have floating 10th ribs! I was never aware of them. They never poked out or hindered my movement until this disc herniation. I remain convinced that this protruding 10th rib is related to the T9-T10 disc herniation. I accept that I most likely have always had “floating” 10th ribs but NOT a protruding right 10th rib! It is now much less protruding. I would like to make further progress because repetitive motion of that rib causes a vague gnawing discomfort (?intercostal nerve) that later keeps me awake at night.

Thanks again for your help and for creating this forum. I have found many of the threads very interesting.

Hart

Donald Corenman, MD, DC
Moderator

November 13, 2012 at 6:49 pm

Post count: 8660

#7398

I have to stand corrected. It appears that you had a full blown radiculopathy of the T9 nerve and resultant weakness of the intercostal muscles associated with that nerve. The muscle weakness might have allowed the floating rib to be uncontrolled with movement and now protrude out. I can tell you that I have never seen this before. This is why I love this forum as I learn new things every day!

Hopefully, this nerve will recover and the motor strength will return. If this nerve can recover, the nerve will grow down from the site of injury about one inch per month. I assume the length of the nerve was initially about twelve inches. You probably have developed as much recovery at this time as you can hope to.

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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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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