Opinion about my x-rays of spine

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nikserer
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April 2, 2014 at 9:56 pm

Post count: 24

#10660

Hello Dr.
I had few days ago CT and MR of my lumbar spine (14 months after L5/S1 spinal fusion and discectomy) with no problems. There where some artifacts showing in surgical site and more in CT than MR, but after all it’s pretty fine images. Fusion is solid (not 100%, but maybe 80%) and my surgeon is satisfied. But I still have some pain in lower left side going to leg. My surgeon said that it is due my scoliosis (and some foraminal stenosis at L2 and L4 levels) and week muscles. I am doing every day exercises for stabilization muscles and walking (how much I can), but I must include also swimming he said.
His conclusion is that there wher two solutions:
1. To try with 3 months of exstensive PT and all I mention earlier, and
2. If pain still persist, he must do posterior only fusion and stabilzation of my whole lumbar spine including three Thoracic vertebre (T10 to sacrum), getting in mind that L5/S1 is already fused…
I would like to hear your opinion as expert with long time experince in this field. Also I am interested is safe to hang out on a bar (for extension) after fusion is solid? I suppose it is risky, but I would like to hear your opinion. I am not doing that in my ripstol because I am scared of getting something wrong. But I miss too much this type of extension for upper back.
I will send you soon link to some images of my new MR and CT scans if you want to see tham.
Thanks a lot for your time.
Best regards
Nikola

Donald Corenman, MD, DC
Moderator

April 6, 2014 at 5:32 am

Post count: 8660

#10683

I am not sure what an 80% solid fusion is. Is there solid bone that connects from L5 to S1 or is it granular bone that connects the two?

The residual pain in your buttock and leg could be from the levels above or from the surgical level at L5-S1. I know you have a relatively large double major scoliosis (55 degrees) as you reported before and that angulation can cause lateral recess or foraminal stenosis (see website) which can cause nerve compression.

The way to find out if this pain origin is still from L5-S1 or from levels above is to do a nerve block of the suspected levels, one at a time. See “pain diary” to understand this concept. If the buttock and leg pain is temporarily relieved by an injection of the L5-S1 level, surgery of the upper levels will probably not help you. However, if pain relief is achieved by injection at L2-3 or L3-4, then it is reasonable to assume that these levels are causing your pain.

If you have a double major scoliosis of 55 degrees, surgery of just the lower curve is not recommended. Surgery is designed to straighten out the curve, at least somewhat. If the correction of your lumbar curve reduces to 25 degrees, then you will be out of balance as the 55 degree curve above will not be compensated by the changed curve of 25 degrees below.

Now, if this surgeon does not correct the bottom curve but just fuses in situ (in place without correction) and decompresses the nerves that were compressed and causing pain, this would work. This technique however ensures that your bottom curve will never be corrected and that is one of the goals of deformity (scoliosis) surgery.

By hanging out on a bar, I assume that alcohol is not involved;) If you want to “hang” by your hands, by all means do so. This is not deleterious to your fusion.

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.

nikserer
Member

April 6, 2014 at 6:33 am

Post count: 24

#10685

Thanks dr. again on your valuable explanation. My surgeon did mention last time some epidurals or block injections, but this time not. As I said, he mention only that two options:
1. Intensive PT including swimming,ridding bike for 3 months…
2. If pain persists – Posterior only stabilization and fusion from T10 to sacrum. I asked him what will be with my upper curve, and he said – we shall monitor it.
I remember that in some previous visits he also mentioned that it should be corrected and fused from T3/T4 to sacrum, but that it is too big surgery.
My questions this time for you dr. are:

1. Can stabilization&fusion from T4 to S1 be done from one surgery?
2. Is it needed to perform nerve block diagnostics/pain med. before surgery even MRI shows where the problem is?

I will post tomorrow few images of my CT and MRI scans and send you link. Also, I will send you translation of MRI radiologist report. I mention to my surgeon radiologist report about foraminal stenosis at L2, L4 and L5 level and some protrusion at I think L4 level, and he didn’t make big attention on that. He said that it is most important that there is not spinal canal stenosis.
Best regards
Nikola

Donald Corenman, MD, DC
Moderator

April 6, 2014 at 9:29 pm

Post count: 8660

#10689

What you have to do is to identify the pain generator. This is diagnosed in my hands with selective nerve root blocks and pain diaries (see website).

Yes, stabilization can be performed in one operation on one day from T3 to the sacrum but many surgeons including myself do this in two separate days as this is a lot of surgery for one surgeon in one day. Generally in my hands, the lumbar spine (from T10-sacrum) is done on one day and the next day or two, the thoracic spine is completed.

If the history and physical examination confirm the nerve involved with pain and the X-rays and MRI confirm where the pain originates, then further testing might not be necessary. For example, if the pain starts in the right SI joint, radiates to the anterior knee with standing and walking, the pain is relieved by sitting or crouching, the dermatome of L4 is diminished and there is evidence of foraminal stenosis at L3-4 on the right, then the L4 root can be implicated.

Most of the time, the history and examination is not that straight forward and diagnostic blocks should be performed.

You can send images via Fedex or UPS for my review. You would have to call the office for shipping information.

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.

nikserer
Member

April 7, 2014 at 3:42 am

Post count: 24

#10691

Hi dr. again,
Here is translation of radiologist report of my lumbar MRI:
“MRI conclusion:
Postoperative status L5-S1 segment: Held order of L5-S1 corps (segment?).
No signs of spinal canal stenosis;
Intraforaminal disco radicular compression of right L2, left L4 and L5 radics;
Pronounced sinistro convex scoliosis of lumbal segment.
MRI control by further clinical indication.”

I am interested in your opinion in few words, even I think you explain me all my situation. I am only pretty anxious because of my surgeon is keeping me so long on “stand-by” even I told him several times that I am in lot of pain.
Thanks a lot on your support. If I am closer to you, for sure I will come to your office.
Nikola

nikserer
Member

April 7, 2014 at 6:23 am

Post count: 24

#10692

Hello dr.,
Here are few links to images of MRI&CT scans of my lumbar spine. I have all images in few folders and I can send them by email. If this is not enough for review, maybe can you give me some of yours email so I can send all images?
Thanks a lot again on your time. There is not so good experts in world like you and most important – good man.

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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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