Pain After Repair of Dural Tear and Pseudomeningocele

Tagged: CSF leak after a microdiscectomy

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koobi336
Participant

April 11, 2019 at 7:38 am

Post count: 10

#30359

Yes, it was the left side L4/L5

Donald Corenman, MD, DC
Moderator

April 11, 2019 at 7:45 am

Post count: 8660

#30361

Symptoms in the leg are more likely residuals from the nerve root compression or irritation from the repair of the dural leak than arachnoiditis.

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.

koobi336
Participant

April 23, 2019 at 11:47 am

Post count: 10

#30394

Hello Dr. Corenman,
I had another MRI last week since my back pain is continuing. If you wouldn’t mind looking, do the results below tell you any clues about where this continuing pain could be coming from? Also, I believe it confirms that this is not arachnoiditis, correct? Thanks for your continued correspondence and help!

CLINICAL DATA: 58-year-old male with lumbar back pain radiating to
the buttock and foot. Left leg numbness. Lumbar surgery in December
2018 with subsequent surgical repair of pseudomeningocele on
02/07/2019.

EXAM:
MRI LUMBAR SPINE WITHOUT AND WITH CONTRAST

TECHNIQUE:
Multiplanar and multiecho pulse sequences of the lumbar spine were
obtained without and with intravenous contrast.

CONTRAST: 16mL MULTIHANCE GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN

COMPARISON: 03/06/2019 lumbar MRI, 01/24/2019, and earlier.

FINDINGS:
Segmentation: Normal lumbar segmentation designated as on the prior
studies.

Alignment: Stable vertebral height and alignment. Mild straightening
of lower lumbar lordosis. No significant spondylolisthesis.

Vertebrae: Small chronic endplate Schmorl’s nodes in the lower
thoracic spine and L1. Bone marrow signal remains normal. No marrow
edema or evidence of acute osseous abnormality. Intact visible
sacrum and SI joints.

Conus medullaris and cauda equina: Conus extends to the L1 level.
Conus and cauda equina appear normal. No abnormal intradural
enhancement. Mild posterior dural thickening and enhancement at
L4-L5 is described below.

Paraspinal and other soft tissues: Negative visible abdominal
viscera.

A quadrilateral shaped residual postoperative fluid collection in
the left laminectomy space at L4-L5 is further described below, and
is decreased since 03/06/2019 now encompassing 11 x 18 x 33
millimeters (AP by transverse by CC) versus 18 x 24 x 40 millimeters
previously.

Disc levels:

T11-T12 through L3-L4 are unchanged and largely unremarkable.

L4-L5: Sequelae of left laminectomy. The residual laminectomy space
fluid collection has decreased in size since March. The collection
appears simple but is mildly rim enhancing, and there is associated
mild left posterior dural convexity rim enhancement (series 9, image
34). However, there is no mass effect on the thecal sac, the
posterior contour which has mildly enlarged since March. No
surrounding soft tissue edema. A smaller subcutaneous fluid
collection at the skin incision site has also regressed with trace
residual (series 6, image 32). Stable other postoperative changes
tracking from this fluid collection to the skin surface.

Stable disc desiccation with minor circumferential disc bulge and
small broad-based central disc protrusion (series 6, image 31).
Stable mild facet hypertrophy. Capacious thecal sac now at this
level. No nerve root clumping or thickening. No convincing stenosis.

L5-S1: Stable and negative.

IMPRESSION:
1. Satisfactory postoperative appearance following repair of dural
leak in February. Decreasing residual small left L4-L5 laminectomy
space fluid collection with no mass effect on the thecal sac. Mild
postoperative dural thickening without adverse features; no nerve
root thickening, clumping, or enhancement.
2. Stable L4-L5 disc degeneration with small broad-based protrusion.
No convincing neural impingement.
3. Other lumbar levels are stable.

Donald Corenman, MD, DC
Moderator

April 23, 2019 at 6:19 pm

Post count: 8660

#30395

Your images rule out arachnoiditis and mass effect from seroma or pseudomeningeocele. There are no “smoking guns” noted and no further compression. It seems to be a “matter of time” to allow the root to heal.

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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