Pars Defect Repair After Prior ALIF Surgery at L5-S1 Level, Can it be Done???

Tagged: back pain, lumbar artificial discs, pars defect repair

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bwink23
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April 9, 2015 at 11:10 am

Post count: 16

#18755

Hello Dr. Corenman, i have what i believe is a unique situation that needs your level of expertise. I had ALIF fusion at L5-S1 due to unilateral Pars Interarticularis Defect on my left side. It was diagnosed by CT Scan and showed 2mm displacement of my L5 vertebra most noticed on the flexion/extension X-rays. I also had bad L4-L5 degeneration of the disc. My surgeon said it was “greenish” in color, whatever that means…So, i had a 2-level hybrid fusion at L5-S1 and M6 ADR at L4-L5….Total discectomy at both levels…at least as much as you can do from the anterior approach. I had 3 surgeons give me the same surgical approach, so i went with it.

Now the tricky part. I still have pain on my left side, not into the hip and legs as it once was to where i couldn’t walk at all. It seems bio-mechanical in nature. When i twist to the left, i get audible pops on my left side. It was there before surgery as well. My surgery was 1 year and 2 months ago, and it was extremely difficult to recover from, still not there. The ADR looks good, good disc and good placement. My ALIF was not standalone, it was fixated with a plate over it. I have had no prior surgeries before this one. My MRI’s have never shown spinal stenosis in my lower back.

I hope i have been detailed enough to give a good background. THE REAL QUESTION….can i have a Pars Defect Repair in my current state, and be successful with adding additional stability, WITHOUT extra instrumentation?? My FACETS are in good shape from MRIS….Now that all signs of Degenerative Disease are gone, would i now be a candidate for Pars Defect Repair?? I am 38 years of age, don’t smoke or drink and in relatively good health otherwise.

Dr. Corenmean, do you have experience with Pars Repair surgeries, and how have the outcomes been?

Donald Corenman, MD, DC
Moderator

April 12, 2015 at 10:47 am

Post count: 8660

#18967

Pars fractures in the face of a solid fusion at L5-S1 should not give you any pain. The solid fusion in the front will not allow any motion in the rear of the spine. If you did develop a pseudoarthoses (lack of fusion) at L5-S1-this could allow motion and pain.

The other possibility if you have a solid fusion at L5-S1 is that the L4-5 level with the ADR (artificial disc replacement) is allowing motion of degenerative facets at this level.

“When i twist to the left, i get audible pops on my left side. It was there before surgery as well”. This sounds like a bad facet associated with the L4-5 level. The way to figure this out is to get a facet block (see website) and keep a pain diary. Good temporary pain relief indicates these facets as the pain generator. You then might be a candidate for rhizotomy (see website).

Using the rules I use for cervical artificial discs (I don’t like to implant lumbar artificial discs for the very reason you are going through this now), I do not implant ADRs in patients who have very degenerative levels. The collapse of the disc space also degenerates the facets and restoring the disc height also distracts these facets. Pain can be the result.

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.

bwink23
Participant

April 25, 2015 at 4:14 pm

Post count: 16

#19216

I had a facet block done at L5-S1 and L4-L5 about 8 months after surgery on my left side with no pain relief. Is it possible this fracture was reopened when both levels were distracted, this causing continued pain? My pain is very localized, surely it can’t be coincidence the pain is in the area of the pars defect? Could the bones have healed without being lined up properly, which is causing pain in the area due to improper alignment along the pars interarticulis? Even if the fracture itself is not a pain generator, couldn’t it heal incorrectly and cause ligaments and or tendons to cause pain? My MRI’s never showed arthritic facets before or after surgery. It just seems too conincidental that the localized pain i have on my left side just happens to be the general location of the pars fracture. I can put one finger on my left side and put it right on the spot of chronic pain. Can’t a CT scan evaluate that fracture and access whether it’s causing anything connectedr above and below it to not function correctly? I read a previous post that you did not like anterior fusions for pars defects because you believe they should be supported from the posterior. Wouldn’t cleaning out the break and aligning it, setting it with a screw and letting it fuse restore that posterior support? Couldn’t fixing that pars defect indirectly influence the functionality of everything in the area?

Donald Corenman, MD, DC
Moderator

April 26, 2015 at 7:56 am

Post count: 8660

#19221

If you have a solid fusion of the disc space of L5-S1, this should prevent any motion of the fractured fragment in the rear of the spine. When you move, there should be no stress on this fragment.

You note that the facets blocks gave you no relief. Did you pay attention to the first three hours after these blocks? Short term relief (and only short term relief in the first three hours) is the important indicator of facet pain generation (see pain diary).

A CT scan would be helpful to determine fusion and the location of the pars fractures. Additional information is always helpful.

I think that the problem is still probably from the artificial disc but a new CT scan would be helpful. Unfortunately, the ADR will obscure the images somewhat (from all that metal).

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.

biofreeze
Participant

April 26, 2015 at 9:37 am

Post count: 99

#19228

Hi. Dr. Coreman:

I have read some of your other posts discussing the bone spur that lies beneath the pars defect and if the pars fracture and bone spur are not removed that this bones spur could still cause subsequent back/leg pain after surgery. Hence the reason for doing TLIF over ALIF.

Couuld existing boan spur be part of the problem in this case ?

If so, could surgeon go back in and simply remove pars fracture and bone spur ?

Please let us know. Thank you !!

Donald Corenman, MD, DC
Moderator

April 26, 2015 at 1:01 pm

Post count: 8660

#19235

Normally, a fusion from the front can “lift up” the disc and reduce the compression of the posterior pars bone spurs. It is still possible that compression of the L5 root is causing your pain.

You could have a selective nerve root block (SNRB-see website) to block the L5 nerve on the side of pain. Good temporary results (see pain diary) could indicate that decompression of this nerve would give good relief.

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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