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

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Lollipop
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May 23, 2014 at 6:47 am

Post count: 31

#10884

AdHi Dr. Corenman,

Quick PMH: Age 56, 5’2” 135 pounds, active and nonsmoker. L4-L5 decompression with partial discectomy 11/12. L4 pars fracture 10/13 via MRI. Osteoporosis getting second yearly Reclast infusion in June. Prior cervical laminoplasty 2/09.

I finally followed up with my surgeon two days ago. I have continued to have left lateral/anterior thigh pain and now occurs on the right leg too. The discomfort is never both thighs at once and is not limiting my ADL’s. I have had chronic low back burning but it has gotten worse in the past month or so. It is ok when I first get up in the morning, but worsens after being up and walking around for about 4-5 minutes. After sitting a bit it usually quiets down. I try to get 10,000 steps in a day and in the past two weeks I have noticed that the burning gets much worse at about 1/4 mile and my low back just feels really fatigued at the same time. Yesterday I could only walk 1 mile (as opposed to the 2 I usually do, due to the increased intensity of burning/fatigue. I have also noticed a clicking in my low back as I move my left leg forward during my gait in the past week.

My doctor did an x-ray and told me two things. The L4 vertebrae has slipped over L5 enough to impinge the nerve root… I believe the left is worse that the right. He wants me to see a pain management doc for a steroid injection. My ortho doc wants to see me again, two months after that OR sooner if there is any worsening of the burning/fatigue. He did mention that I may need a fusion if things don’t improve or if they get worse.

What is your opinion about these new developments. I appreciate any feedback. Thank you so much!

Lollipop
Participant

May 24, 2014 at 4:50 am

Post count: 31

#10886

One additional question…. Would a Chiropractor be ok to realign the spine or would it not be advised?

Donald Corenman, MD, DC
Moderator

May 27, 2014 at 5:40 am

Post count: 8660

#10890

I am going to assume that you had preexisting fractures of the pars prior to your microdiscectomy. The slip and nerve root impingement is relatively typical for this disorder as the slip advances or reactive bone spur formation occurs.

Since this fracture is established, you can try chiropractic but you don’t want to mobilize this segment as increased motion can lead to further nerve impingement.

A steroid injection is a good idea to try and reduce the nerve irritation. A good rehab program with core strengthening would be helpful also.

If symptoms continue and are not reduced with the above, a decompression and fusion should be helpful.

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 30, 2014 at 9:15 am

Post count: 31

#11626

Hi,
Touching base again… I developed the L4 pars fracture a year or so after my L4/5 decompression with partial discectomy in November 2012. I had a steroid injection in July for my left leg pain. I have been better since. Now, the right side has kicked up over the past couple of months. The low back burning was gone for a few days post injection then came back. I have no discomfort when I get up in the morning or if I sit down for awhile. After I am up and moving my low back starts to burn, and after walking about 1/2 mile a pain starts shooting in my right lateral thigh. Sometimes my right buttock has pain also. The shooting pain in my right lateral thigh also happens when standing. The shooting pain varies in frequency and intensity…Last two weeks it is getting worse. If I happen to step off a curb hard I get a horrible pain in my low back.

I saw my surgeon today and he says a fusion would improve the pain, as it seems the nerve root is being impinged. He said the pars fracture is most likely due to my decompression/discectomy. He said the spondylolisthesis will not progress. Of course, surgery is my call. I do weight training twice weekly with concentration on my core and walk 10,000 plus steps daily.

Would fusion surgery alleviate the low back burning/fatigue and shooting pain in thigh for good? It is a big surgery requiring 3-4 days in the hospital per my doc. I am active and want to remain so. Do you think it would be better to do this sooner than later in terms of a better outcome? Any information you share is greatly appreciated! Thank you!

Donald Corenman, MD, DC
Moderator

October 30, 2014 at 7:59 pm

Post count: 8660

#11629

Your new right sided back and leg pain is typical for foraminal stenosis. The pain occurs with standing and walking and is relieved with sitting or bending forward (like holing onto a shopping cart). See the section on foraminal stenosis for a complete explanation.

Foraminal stenosis is common with pars fractures. The “back burning” is the initial compression of the nerve root talking. With this initial compression, the root only refers pain to the lower back. As the root is further affected from compression, the pain will start to radiate down the leg. Sitting, crouching or leaning over a counter relieves the compression and the leg (and back) starts to feel better.

If this is what I suspect, then fusion (with a decompression) will relieve symptoms. The more the root is compressed, the more chance of permanent damage but the risk is not high.

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

June 1, 2015 at 10:50 am

Post count: 31

#19612

Hi Dr. Corenman,
I had an L4-5 partial discectomy with decompression in November 2012. I did well until developing lumbar tightness/intense burning with walking along with buttock pain radiating to L lateral thigh about a year later. I had an MRI w and w/o contrast in October 2013 which 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.

Medrol dose pack and eventual steroid injection did help. Medrol dose pack helped for a week and injection for three days.

I have continued to deal with the discomfort, which now includes my R thigh. I have been weight training including core strengthening for years. I am a fit 57 y.o. female and do have osteoporosis for which I have had Reclast infusion the past two summers.

I have seen my surgeon a few times in the past two years and he has done x-rays which have shown a Grade 1 spondylolisthesis with stable spine. He suggested a fusion of L4-5 based on my symptoms, but I have been hesitant. My lumbar burning continues with intermittent pain down one or both lateral thighs and a clicking I feel in my lumbar region as I move my left leg forward as I walk any distance. My back discomfort is getting worse and my back is starting to feel fatigued/overloaded with ADL’s/cleaning/on my feet for long periods of time.

I was not comfortable doing surgery without an up to date MRI. My surgeon ordered one last week at my request showing:

L2-L3 There is disc space narrowing. There are discogenic changes in the adjacent endplates. There is posterior disc osteophyte complex. There are mild hypertrophic facet changes bilaterally. There is mild central canal stenosis. The neural foramina are patent.

L3-L4 The patient is s/p posterior laminectomy. There is granulation tissue posteriorly at the laminectomy site. There are discogenic changes in the adjacent endplates. There is mild diffuse disc bulge. There are mild hypertrophic facet changes bilaterally. There is no significant central canal stenosis. There is moderate bilateral neural foraminal stenosis.

L4-L5 The patient is s/p posterior laminectomy. There is circumferential granulation tissue within the epidural space. There is grade 1 spondylolisthesis. There is a medially projecting 3.3 mm left synovial cyst. This causes moderate impression on the subarachnoid space. There is a left lateral herniated disc. There are moderate hypertrophic facet changes bilaterally. There is severe left neural foraminal stenosis.

L5-S1 The patient is s/p posterior laminectomy. There is no significant granulation tissue. There is disc space narrowing. There are discogenic changes in the adjacent endplates. There is posterior disc osteophyte disc complex. There is no significant central canal or neural foraminal stenosis.

On a side note: I had to have a cervical laminoplasty C3-C6 in 2009 due to severe stenosis. I have done great since.

My surgeon is suggesting a L3-L4 TLIF with screws and rods, cadaver bone with bone morphogenic protein.
Your thoughts? Thanks so much!
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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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