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
Participant

September 13, 2016 at 9:44 am

Post count: 31

#22967

Hello and thank you so much.
I am shying away from such intense surgery. I see my surgeon tomorrow and have one major question for you. Is the revision of L4-5 something I should do now or can it wait? Could I do more damage to the area if I wait?

Donald Corenman, MD, DC
Moderator

September 14, 2016 at 5:18 am

Post count: 8660

#22980

I don’t think that waiting to repair the L4-5 level will cause any unsolvable problems. There is the possibility of hardware breakage as motion can fatigue the metal but that would be unusual and still a problem that can be overcome. I am concerned that you might not need an L3-S1 fusion so another opinion would 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

September 14, 2016 at 2:28 pm

Post count: 31

#22992

Hello Dr. Corenman,
I saw my ortho surgeon this morning. He said he wouldn’t do a TLIF at L4-5 due to the scar tissue present and increased possible nerve damage with that procedure. I have had a L4-5 decompression with partial discectomy in 2012 and had the rod and pedicle screw fusion one year ago, so I do understand the increased risk of damaging nerves. This would be the third surgery there in four years. He said he would use BMP and place a larger screw at Left L4, leaving the other screws in place if the look good.
He said he would do rod and pedicle screws at L3-4… I THINK because of the loss of disc height and foraminal narrowing… He said he would do a TLIF at L5-S1 as there is no disc space and some of my symptoms are indicative of that.
What are your thoughts, and do ALL pseudarthroses require a revision? Thank you again, as always!

Donald Corenman, MD, DC
Moderator

September 15, 2016 at 5:34 am

Post count: 8660

#22993

First, you have to ask what the pain generator is and what needs to be done to fix it. The most likely pain generator is the pseudoarthrosis at L4-5. It is hard a this distance to know what L3-4 and L5-S1 looks like or how they correlate to your symptoms. I am not a fan of simply fusing them for degenerative changes if your symptoms stem more from the L4-5 level. That correlation needs to be done by an accurate history and physical examination, careful perusal of the images and then possible further diagnostic testing such as discogram or SNRB. A three level fusion does limit your future activity and should not be taken lightly.

Second, I would disagree that a TLIF should be avoided at L4-5. Yes, BMP will be helpful to create a fusion but with the fusion bed of the posterolateral gutter already scarred by the prior attempt of fusion, I would recommend a TLIF to make sure this level has the best chance of fusion. Scar tissue should not be a factor as this is dealt with every day by spine surgeons.

You need to have reasons to have a three level fusion. You might have them but without symptom correlation or testing to determine what levels are causing what symptoms, I would be very cautious proceeding.

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 10, 2016 at 4:06 pm

Post count: 31

#23176

Hi Dr. Corenman,
I got a second opinion today from a neurosurgeon regarding my arthrodesis and wanted to update you. He showed me the CT scan and totally explained that the Left L4 pedicle screw was not placed at an angle but pretty much straight in. It is moving and is impinging on nerves. It has also caused a new pars fracture on the Right due to movement and the Right L4 screw is starting to show a halo affect. He said that I have no arthritis, which is a BIG relief to me, in that we can fix this and I can move forward. I thought some of my pain was due to beginning arthritis.

He does not feel the Left L4 will support a screw anymore so he will do a TLIF at L4-5 using a cage, some of my bone and BMP. He will remove all previous hardware. He will place new rods and pedicle screws L3-5 on the Right and pedicle screws at L3 and L5 on the left, if I understood him correctly. He sees no need to involve L5-S1 at this time, as my orthopedic surgeon had planned. I also had x-rays today to help him see and maintain the proper curvature of my spine. I am encouraged and plan to get this done between Thanksgiving and Christmas.

Thank you so much for your encouragement to get a second opinion. You are so kind to have this forum!

Donald Corenman, MD, DC
Moderator

October 11, 2016 at 6:41 am

Post count: 8660

#23179

Excellent! I am glad that you will have a revision with a TLIF. I assume that the L3-4 level has to be involved du to a lack of good screw positioning but I wonder if you need the L3-4 level involved? Even if there is a “bad screw hole” in the L4 pedicle, a hook can be used above the lamina at L4 instead of involving the L3-4 level. These hooks are “old school” but a valuable technique to avoid involving another level.

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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