Ongoing pain after direct pars repair

Tagged: Pars repair failure

Viewing 6 posts - 1 through 6 (of 6 total)

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matthew143
Participant

November 14, 2020 at 5:09 am

Post count: 3

#33365

Hi Dr. Corenman,

I’m a 17 y/o male who received a bilateral direct pars repair at L5/S1 in February 2019, but I am still in great pain and wondering what to do next. I first noticed my low back pain in April 2018 and was diagnosed with bilateral spondylolysis with a grade 1 slip. I spent many months bracing, immobilizing, and doing physical therapy, but the pain persisted and started going down the legs, so I opted for surgery. My surgeon placed screws inside the pars fractures (Buck’s technique) and used bone graft from my hip inside the gaps. At the 3-month follow up I was in the same pain as before surgery, and a CT showed no signs of the bones healing. The surgeon could not explain why I was still in pain and cleared me for activity anyway. Several months of physical therapy did not help the pain, and I had to start walking with a cane.

Currently, I stay in bed most of the day to manage my pain – I can stand or sit for about 30 minutes. The pain is always on one side at a time, in the low back and leg, but recently it has been on the right side 99% of the time. I can temporarily decrease my pain by standing only on the non-hurting leg. Ice helps my pain much better than NSAIDs. Any physical activity increases the pain (walking, bending, sitting, etc), and it hurts to lie on my side. At its worst, the pain is at an 8 out of 10 but can sometimes go down to a 1 when resting.

I have seen a few other surgeons, but they haven’t been able to explain why I am still in pain and seem to think that I am fine because my discs look normal. On my most recent images, the x-ray reported “possible nonunion” and my MRI (w/wo contrast) supposedly didn’t show anything significant, but I can copy the report here just in case. These are from 05/20, but my pain hasn’t changed much since then. I haven’t been able to get a newer CT since my original one.

——-

FINDINGS:
There are 5 normal lumbarized appearing vertebral bodies, with no transitional vertebral body segments, with conus terminating above T12, above the field-of-view the current study.
Alignment and vertebral body height: 15° levoscoliosis with low-grade right sided disc space narrowing at L1-L2 through L5-S1. 4 mm L5 anterior to S1 spondylolisthesis. Normal lordosis. No compression fractures.
Bone marrow signal: Normal. Paraspinal soft tissues: Normal. Other findings: None.

The spinal canal and foramina are congenitally ample, limiting neural compression.
T12-L1: No encroachment. High-grade disc space narrowing and desiccation preferentially anteriorly. Normal posterior elements.
L1-L2: No encroachment. Moderate grade disc space narrowing desiccation preferentially anteriorly. Normal posterior elements.
L2-L3, L3-L4, L4-L5: No encroachment. Normal discs and posterior elements.
L5-S1: No encroachment. Normal disc signal with minimal loss of height. Status post posterior fusion with metallic hardware fusing the bilateral facet joints, producing metal artifact, slightly distorting and obscuring visualization of the facet joints. Low-grade residual L5 anterior to S1 spondylolisthesis.

Post IV contrast scanning demonstrating no abnormal unusual enhancement.

——-

Are you able to tell what is causing the pain? Are the unhealed bones causing motion that compresses nerves? I am not familiar enough with the anatomy to know what is going on, and I would be very grateful for an explanation of what might be causing my pain and what I should pursue next. I am willing to get a fusion if that is the best option.

Thank you!

Donald Corenman, MD, DC
Moderator

November 14, 2020 at 10:02 am

Post count: 8660

#33366

Most likely, you have a non-union of your attempted pars repair. The pain is likely to be generated by the bone/screw interface which is mobile if the pars did not heal. A new CT should confirm this and possibly demonstrate haloing around the screws. If these fractures did heal, it would be a different story.

Once you confirm a non-union, you can demonstrate the fractures as the pain generators by having “pars blocks” performed. This is a numbing agent injected around the pars with temporary pain relief. See https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/

If you have a non-union and a diagnostic pars block, then you would need a fusion of this level. In my opinion. you have one chance to heal these fractures through surgery and if it doesn’t work, a fusion is necessary.

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.

matthew143
Participant

November 14, 2020 at 2:58 pm

Post count: 3

#33367

Thank you so much, Dr. Corenman! I will make sure to get an updated CT and a diagnostic pars block at my next doctor. Would a fusion be more difficult than normal with the existing screws having to be removed? I am wondering because I live in a small city in Virginia, and the most experienced surgeons are a few hours away, but there are some surgeons nearby who perform fusions. I want to make sure my next procedure is the last one. Also, is TLIF the best approach for this case?

Donald Corenman, MD, DC
Moderator

November 14, 2020 at 3:58 pm

Post count: 8660

#33368

A fusion is not more difficult. It is generally easy to remove the pars screws, especially if there is no fusion of the pars. A TLIF is what is needed for your fusion if necessary but an ALIF with a posterior fusion is acceptable too. Go to the best surgeon you can find.

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.

matthew143
Participant

April 7, 2021 at 11:05 pm

Post count: 3

#33906

Hi Dr. Corenman,

I wanted to give an update and ask some more questions if you’d be willing to answer them. I received an L5-S1 fusion 8 weeks ago, but I’m experiencing the same type of pain as before surgery except worse, and I haven’t felt much improvement.

I got scheduled for surgery because my new CT showed unhealed pars fractures and haloing around the screws like you predicted, so my surgeon said that the pain was likely being caused by the bone/screw interface. I wasn’t able to get a pars block but got a CT myelogram for a better look at the area. They performed a TLIF through the midline incision of my original surgery and found that my original screws were loose before they removed them. My x-rays at the 6-week post-op looked normal.

Recovery was going fine until I was taken off hydromorphone, and now the most activity I can tolerate is short walks every hour using a walker. My current pain description is stabbing pain in the low back (just above the glutes and to the side of the spine close to the midline) with aching pain in the leg going down to the foot. It affects one side of my back at a time and the corresponding leg, but the right side hurts most of the time. Any physical activity involving the legs will exacerbate the pain. The pain will switch into the non-hurting side with certain movements like putting too much weight on that leg or lying on that side, or sometimes randomly while lying on my back without moving much. A strange symptom is that whenever my back pain is bad it gets rid of a separate pain issue in my pelvis (suspected pudendal neuralgia that started after surgery for pilonidal disease a year ago) but this might not be related.

I’m wondering if you think my pain will improve with time or if it’s possible I’ve had a different pain generator all along. Since my pain worsened after a surgery at L5-S1 would that indicate that the pain is coming from there? Are there other possible sources of my pain that wouldn’t show on my images? Another thing I’m confused about is that my back pain is located an inch or two below the incision. My physical therapist says it’s the area of the SI joints; could this possibly be the pain generator? It might be too early to come to any conclusions, but I am worried because my functioning is still so limited by the pain.

Thank you!

Donald Corenman, MD, DC
Moderator

April 8, 2021 at 3:00 pm

Post count: 8660

#33909

Most likely, you had developed pain due to the non-union of the pars repairs.

If you have new onset leg pain and increased lower back pain after surgery, I would recommend labs tests just to make sure you don’t have an infection and a new MRI to make sure there is no seroma (collection of fluid) compressing the roots. It is highly unlikely that you have sacroiliac generated pain. Typically, pain somewhat below the surgery is typical but not to the intensity that you note. This still could be post-surgical pain but just delayed resolution.

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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