pain pattern had me confused

Tagged: Lumbsr herniation and yes or no surgery

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elerne
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September 16, 2015 at 11:58 am

Post count: 2

#20331

Dear Dr. Corenman,
I would like to have your appreciated evaluation of my MRI findings. My lower back pain started over 7 weeks ago progressively increasing to the point that I had to go to ER on 8/2. Since then I was checked by 2 Neurosurgeons they both are of the same opinion which is that the pain is caused by L5S1 right paracentral herniation. One of the doctor is offering microdiscectomy while the other wants me to try PT and conservative for 6 more weeks.
What have me concerned is the pain pattern which I can see it doesn’t correlate with the Dx. At the beginning I was presented to the ER with stabbing and burning pain in my lower back going to the right buttock. This pain also extended to my both legs in a different pattern which was alternation of stabbing, burning, numbness and pins and needles feeling. In the legs this variety of disconffort and pain manifested primarily on posterior thighs and calfs and it went all down to both hills, plantar and all toes. Like I said the pain in my legs was very difficult to describe. I have never had weakness in any of my legs. Now the pain have come down to a 2/10, still on both legs a little bit more on the left. I opted out of surgery and I currently doing PT 3 times per week. Taking Celebrex 200 mg prn and flexeril 10 mg prn also.

Here is my MRI:
PROCEDURE: LUMBAR SPINE MRI WO CON CLINICAL INDICATION: EVAL. BACK PAIN BACK PAIN RADIATING TO BOTH LEGS COMPARISON: Correlation is made with CT lumbar spine from 5:07 AM on the same day. TECHNIQUE: Noncontrast multiplanar MR of the lumbar spine performed using standard pulse sequences. DISCUSSION: Vertebral bodies are of normal height and signal intensity. There is no spondylolisthesis. Tip of conus is normally positioned. Serial axial sections through the disc spaces demonstrate: T11-12: Not studied in the axial section but grossly unremarkable. T12-L1: Small Schmorl’s node present. There is a tiny left paracentral disc herniation with associated spur mildly indenting ventral thecal sac. Central canal and neural foramina are patent. L1-2: Minimal disc bulge and spurring asymmetric on the left barely indenting ventral thecal sac. Central canal and neural foramina are patent. L2-3: There is relative preservation of disc height without a significant posterior disc bulge, herniation, spinal stenosis or neural foraminal encroachment. L3-4: There is relative preservation of disc height without a significant posterior disc bulge, herniation, spinal stenosis or neural foraminal encroachment. L4-5: There is relative preservation of disc height without a significant posterior disc bulge, herniation, spinal stenosis or neural foraminal encroachment. There is mild facet hypertrophy. Central canal and neural foramina are patent. L5-S1: There is relative disc desiccation and disc space narrowing. There is a partially calcified right paracentral disc herniation with annular fissure compressing thecal sac and compressing the right S1 nerve root in the right lateral recess. There is mild narrowing of the entrance to the right neural foramen. Left neural foramen is patent. There is no central canal stenosis. IMPRESSION: At L5-S1 there is a partially calcified right paracentral disc herniation compressing the right S1 nerve root. There is mild stenosis entrance to the right neural foramen. Other findings are as described above.

My question is: Do you think my pain correlates to the MRI findings? should I look for a 3rd evaluation? Was opting out of surgery a good decision?
By the way they also did MRI on brain + cervical and toraxic spine, they all came out normal.
I would really appreciate you attention

Donald Corenman, MD, DC
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September 20, 2015 at 5:22 pm

Post count: 8660

#20379

Lets go through your symptoms first. “At the beginning I was presented to the ER with stabbing and burning pain in my lower back going to the right buttock. This pain also extended to my both legs in a different pattern which was alternation of stabbing, burning, numbness and pins and needles feeling. In the legs this variety of disconffort and pain manifested primarily on posterior thighs and calfs and it went all down to both hills, plantar and all toes.

This pattern could be from central stenosis but the report denies this possibility. Did I say that I don’t always trust a radiological report as I have found errors on these not uncommonly?

Your report notes “L5-S1: There is relative disc desiccation and disc space narrowing. There is a partially calcified right paracentral disc herniation with annular fissure compressing thecal sac and compressing the right S1 nerve root in the right lateral recess”. Calcification takes some time to occur so I assume this herniation was present for at least six months. This calcification should indicate no real change but obviously your symptoms would disagree with that assessment. I will assume that there are some subtle findings that have been overlooked. That or you had a physical motion that stretched your root (or roots) and created an injury to the S1 nerve.

If your symptoms have diminished enough that you can live with them and you have no motor weakness, you then did make the right call. If you still have some concern, impairment or difficulty with the symptoms, I would get an epidural at the L5-S1 level to “calm down” the nerve roots and see if symptoms can be improved.

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.

elerne
Participant

September 21, 2015 at 8:47 am

Post count: 2

#20389

Dr. Corenman now that you said it, I do remember feeling like an electric shock going down my both legs while I was doing calfs rises at the gym a week before my wife rushed me to the ER. It did not feel too hard but I do remember that was something different than I never felt before. Then the pain kicked in progressively increasing for a week. I also remember when I was 21 having some sciatica issues on my right side, but at that time in my country there was not MRI so it was difficult to know for sure was going on on that same disc. I was told by the Doctor at that moment that it was probably a bulging disc in my lumbar. I did some PT with some NSAIDS and after few weeks the pain and the symptoms went away. Now I am 41, so 20 years is a more than enough for that hernia to calcified.
So, being this as you said “that or you had a physical motion that stretched your root (or roots) and created an injury to the S1 nerve” what most likely happened should I still avoid surgery? Or is it better to take that calcified annular tear out? That tear is not going to shrink right? I am afraid not being able to run and play with my 4 year old son again.
Thanks again and God bless you
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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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