one or two level lumbar fusion?

Tagged: Degeneration above a planned lumbar fusion level

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peewee
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May 20, 2016 at 12:37 pm

Post count: 2

#22207

Hi Dr. Corenman, I am a 57 year old male diagnosed six months ago as having severe disk degeneration at the L5-S1 level. This disk herniated 20+ years ago and at that time I had severe sciatica however it subsided w/o surgery. I haven’t had any issues with it until six months ago. MRI says “moderate/severe intervertebral disc height loss ( no hydration)with mild endplate degenerative change and small broadbased eccentric to the right disc protrusion with posterior annular tear results in minimal mass effect right ventral thecal sac and abuts right and left S1 nerve roots.” The last six months I have been experiencing a continual burning ache center lumbar at the belt level along with “pins and needles” on the bottom of my right foot. Lately, the pain has expanded to upper buttocks/hips, and my legs sometimes feel rubbery. Over the last five months, I have tried physical therapy, epidural steroid injections (3), and facet block injections, all to no avail. My neurosurgeon recently suggested fusion at this level. I am considering the fusion however this is the dilemma— the facet joints at the next level up, L4-L5, are severely hypertrophic(double normal size) with bone endema and mild fluid in the joint. Also a 5mm posterior synovial cyst is present, though not within the spinal canal. It was suggested that I might want to consider a two-level fusion , L5-S1 and L4-L5, because the facets at L4-L5 are in rough shape and will have more stress on them if L5-S1 is fused. This makes sense however the L4-L5 disk is in decent shape with good height and hydration and no visible tears. Should the condition of the facet joints take precedent over the disk condition? I feel more comfortable with a one-level fusion but surely would not want to be back in the operating room having L4-L5 fused a short time after having L5-S1 fused. Thanks very much for your response.

Donald Corenman, MD, DC
Moderator

May 21, 2016 at 9:59 am

Post count: 8660

#22212

You have two symptoms that indicate both probable disc pain and nerve root compression. When you initially had your disc herniation 20 years ago, this started the degenerative cascade of L5-S1. Over years, the disc broke down and the purpose of the disc (shock absorption) slowly became impaired. Finally, you developed endplate fractures (“mild endplate degenerative change”) which when loaded (standing and especially impact activities) cause lower back pain.

The “pins and needles” (paresthesias) is most likely from the compression of the right S1 or L5 nerve root (“minimal mass effect right ventral thecal sac and abuts right and left S1 nerve roots.”). If the paresthesias are from standing, it most likely is L5. If from sitting, most likely from S1.

Your L4-5 level is the biggest question mark. The remark “(the facets) are severely hypertrophic(double normal size) with bone edema and mild fluid in the joint” indicates significant degeneration of these joints. This brings up three points; do these facets cause pain, is there a degenerative slip and what might happen to this level with a fusion of L5-S1?

First, if there is a slip of this level (see https://neckandback.com/conditions/degenerative-spondylolisthesis-or-spondlylolysthesis/), then L4-5 will become a problem if not now then in the future and needs to be included in the fusion. This slip is determined by flexion/extension X-rays.

If there is no slip and the level is stable on flexion/extension X-rays, then the question of pain generation from this level is the next question. If the disc is relatively normal and the facets are the only degenerative change noted, then facet blocks are in order. If the facet numbing injections give you good temporary relief (see pain diary https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/), rhizotomies or ablations can be performed to treat these pain generators.

The last question is if this level is left out of the fusion, what will happen to it in the future? If stable and left out of the surgery, it certainly can become a problem in the future-so should you add it into the fusion to prevent future surgery? This is a question that cannot easily be answered. With this situation, I educate the patient and give them the option of adding this level or leaving it out. L4-5 fusion can easily be added in the future but of course, you would have to go through the postoperative period just as you would with the L5-S1 level.

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.

peewee
Participant

May 22, 2016 at 9:43 am

Post count: 2

#22225

Thanks very much Dr Corenman for the thorough response. I had two facet block injections last month at the L4-L5 level and there was no reduction in my lumbar pain so even though the facets at that level are severely deteriorated, they don’t appear to be the source of pain. I’ll discuss your point about slippage at L4-L5 with my neurosurgeon. At this point I’m leaning towards including it with the L5-S1 fusion. However I’m very concerned post operative permanent restrictions with a two-level fusion. I’ve been very active through my adult life with tennis, running, landscaping, and at 57 fearful of giving it all up. Can you point me to a source that explains permanent post-operative restrictions for two-level lumbar fusion? Again, thank you very much for the thorough response to my initial question.

Donald Corenman, MD, DC
Moderator

May 22, 2016 at 12:20 pm

Post count: 8660

#22228

If you go to search and review the post-operative restrictions for a two level fusion, I have written extensively about this on the Forum. Two level fusions make me nervous about continuing to landscape unless you are the supervisor/owner and most of the work is performed by your employees. Tennis can be a risk if played with intensity and running is an impact activity which can wear the L3-4 disc eventually. I would advise biking, swimming, paddle boarding and hiking as sports to consider.

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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81 reviews

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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