Pars defect after L4-L5 laminectomy, discectomy

Tagged: Pars defect post surgery and psuedoarthrosis; necessary revision of fusion L4-5; Saw my doc today; any danger in not doing anything

Viewing 6 posts - 1 through 6 (of 53 total)

1 2 3 … 7 8 9 Next

Author

Posts
Lollipop
Participant

October 18, 2013 at 10:37 pm

Post count: 31

#9607

Hi Dr. Corenman,.

I am wondering whether to contact my orthopedic surgeon regarding my recent MRI results. Here’s my spine history in a nutshell. I had a successful cervical laminoplasty with plate fixation C4,5,6 in 2009 for congenital cervical stenosis and spondylosis with myelopathy C3-4, C4-5, C5-6, C6-7. The doc told me I would always be hyper reflexive, have a positive babinski and clonus. I found that really interesting as I’m an R.N. After six weeks I was back to everything, no restrictions. :-)

I have lived with low back pain/spasm for about twenty years…rarely was it incapacitating. Usually, I just had a moderate burning sensation and used ice, heat Motrin to treat. Last September, I developed sciatica down the back of my leg and eventually a horrendous back pain that limited my walking for two days. I ended up getting an MRI via my internist which showed:
1. A posterior central to left paramedian disc herniation measuring 5 mm in AP and 9mm in transverse dimension at L4-L5 causing, ventral thecal impingement and also probable impingement on the intrathecal portion of left L5 nerve root accompanied by a severe central spinal stenosis due to combination of this and hypertrophy of the facets and ligamenta flava.
2. Mild central stenosis at L3-L4 and diffuse bulging of discs associated with degenerative disc disease without spinal stenosis or focal disc herniation at L2-L3 and L5-S1.
I had a lumbar decompression with partial discectomy last November. Follow up x-rays showed stable spine. I was released without restriction. :-)

On a side note, I was diagnosed with osteoporosis in June and had a Reclast infusion due to hx gastric ulcers.

I was peachy for a bit, but began to have intermittent mild pain on lateral side of left thigh from low back to hip and down. It continued off and on. Within about a month I had two consecutive nights where I could not lay on my left side due to severe pain. I was fine during the day….lateral leg pain continued and mildly worse. I saw my surgeon; X-rays of lumbar spine were fine. My leg strength good. I think he said it could be ligaments and if worse I could get a steroid injection. Ok…

I kept on chugging along. I walk (aiming for 10,000+ steps daily) or use ARC trainer and/or elyptical at the Y for an hour. I do weight training 2x/wk….I limit training with any back strain. The pain continued from back to lateral thigh with intermittent tingling in toes. I saw my internist when the toes started. He x-rayed left hip and put me on Medrol dose pack. I was to call him if pain returned a week after I finished dose pack. I had no discomfort on the pack, but it did return along with toe tingling. just had an MRI with/without contrast. It showed:
1. Laminectomy decompressing thecal sac L3 and L5 vertebral body levels with enhancement of postoperative bed and epidural enhancement extending to a portion of the right lateral recess and to a lesser extent left lateral recess L4/5 with component fibrosis. This is nonspecific, but may contribute to patient’s symptoms. No abnormal nerve root enhancement.
2. Interval development of left L4 pars defect.

Can you please interpret my most recent MRI. I have never been told of a pars defect and don’t know if I should let my surgeon know. My internist said he can send me to pain clinic but I’m just going to wait and see how I do. I am 55, 5’1″ and weigh 135. I do not smoke. I feel like I’m becoming a whiner and don’t want that. At the same time, given my 4 year history I want to be proactive. Thank you so very much!!!

Donald Corenman, MD, DC
Moderator

October 20, 2013 at 1:13 am

Post count: 8660

#9617

You have had great results from your two surgeries for nerve and cord compression. I am surprised that you were able to go back to full activity after six weeks from a posterior neck fusion. Time to fusion for a posterior neck takes at least three months. Well, obviously you did well so no need to focus on that surgery.

A pars fracture in the lumbar spine after a decompression surgery is not highly unusual. The initial surgical decompression thins out the pars and if too thin, a fracture occurs. This fracture can cause all the symptoms you describe. Do you have most symptoms with standing and walking or with lying down? I assume your pain is mainly left leg oriented.

The pars connects to the inferior facet at the level of the fracture. Without a pars to support the weight of the vertebra, the foramen collapses and the nerve root is compressed. Also, the fracture causes inflammation and the nerve is right in the path of the inflammatory process.

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.

Lollipop
Participant

October 20, 2013 at 3:21 am

Post count: 31

#9629

Dear Dr. Corenman,

Thank you so much for your response!
I actually had a cervical laminoplasty in 2009, I think that was why I had no restrictions after 6 weeks. ( Dr. Henry Bohlman did it and has since passed.)

The discomfort has been all left buttocks, hip, thigh, toes with the usual burning sensation I always have in lumbar region. I forgot to mention that in the recent MRI general report( not summary) pars defect at left L4 has reactive bone marrow edema which is minimal. I assume this is a recent fracture and the boney region is doing its job to heal on its own.

The general report also states there is severe loss of disc space height demonstrated L5/S1. Also, I have multilevel end plate degenerative changes particularly L5/S1 as seen on prior exam in 2012.. From my understanding, my lumbar decompression/ discectomy would not have improved the L5/S1 disc degeneration. It sounds like L5/S1 is pretty ugly. Is it possible that it will not cause issues or should I not be surprised if I need intervention there sometime in the future? I have been told that my osteoporosis has nothing to do with my spine issues…. It just seems to me that it is a factor in the dejeneration.

Thank you so very much! You are a gift to us, helping us understand our issues better. I know you are a busy man and the fact that you do this in addition is phenomenal!!! :-)

Sarah

Donald Corenman, MD, DC
Moderator

October 20, 2013 at 4:34 am

Post count: 8660

#9632

The burning sensation in your lower back is probably from the multilevel degenerative changes your MRI notes. I will assume that you could live with this long standing pain and the new left buttocks and leg pain is the most concerning issue,

The L5-S1 disc is probably responsible for your lower back pain. This disorder is called isolated disc resorption (IDR) and you can read about it under “causes of lower back pain” on the website.

The pars fracture of L4 is most likely new and the reactive bone changes are the results of attempt to repair (which will not occur unfortunately) as well as reaction to the abnormal motion of this level.

A selective nerve root block with a pain diary (see website) will yield the diagnostic information necessary to determine if that is the correct diagnosis.

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.

Lollipop
Participant

October 20, 2013 at 9:50 am

Post count: 31

#9641

So…. Take a copy of the MRI to my surgeon to follow up for possible nerve block is what I’m understanding?? I just don’t want to cry wolf. Thanks so much!

Donald Corenman, MD, DC
Moderator

October 20, 2013 at 8:18 pm

Post count: 8660

#9643

You have real and significant pain that is affecting your life. You want to have pain relief. How is this crying wolf?

The purpose of your doctor is to determine what your pain origins are and try to solve the problem. Once he discovers that you have a pars fracture and now has a potential pain generator, he can order a selective nerve root block to temporary anesthetize the nerve in the L4-5 foramen. If you gain good temporary pain relief, he can potentially plan a surgery that relieves your pain.

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.
Author

Posts

Viewing 6 posts - 1 through 6 (of 53 total)

1 2 3 … 7 8 9 Next

You must be logged in to reply to this topic.

Donald Corenman, MD, DC

Average rating:

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.

Submit your review
First Name, Last Initial:
Email:
Review Title:
Rating:	1 2 3 4 5
Review:

Check this box to confirm you are human.
Submit Cancel