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  • matthew143
    Participant
    Post count: 3

    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
    Post count: 8455

    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

    matthew143
    Participant
    Post count: 3

    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
    Post count: 8455

    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

    matthew143
    Participant
    Post count: 3

    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
    Post count: 8455

    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

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