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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May 12, 2015 at 4:01 pm

Post count: 16

#19445

Dr. Corenman,

I would like you to take a look at this image if you will please…this is the image of the pars fracture at L5 after surgery.

I would like your expert view on this. I am compiling a list of surgeons with experience in this type of procedure, to repair the pars interarticularis. I noticed you said lamimectomy, which i would like to avoid completely. Is that a bone spur up against my L5 nerve root on my left side? If so, can the bone spur be removed without having to cut out the pars defect? I assure you, the localized pain on my left side is very real. If a direct pars repair can be done, wouldn’t the anterior fusion only aid in the healing and fusing of the pars defect by limiting it’s motion? Do you have experience with Buck’s technique for pars defects?

Anyways, could you look at the image and tell me if that is a bone spur, or what method of treatment surgically you would do to repair this problem? Remember, this is a post-surgical MRI, so all work i had pror to, has been already done for degenerative disc disease, so i am no longer a contraindication to a fracture repair..

Thanks doctor

bwink23
Participant

May 12, 2015 at 4:50 pm

Post count: 16

#19448

Dr. Corenman,

I can’t seem to edit my post with the other image, so i will include it here…this a series of slice views between my L4-L5 ADR and L5-S1 fusion:

The slices are found in the link, so you can get an overall picture of what’s going on between L4-L5 and L5-S1

bwink23
Participant

May 12, 2015 at 6:08 pm

Post count: 16

#19451

Dr. Corenman,

Also, here is a link to the CT Scan about 2 months before surgery, showing the fractured site, it links just to the slices across that level.

Donald Corenman, MD, DC
Moderator

May 12, 2015 at 6:48 pm

Post count: 8660

#19454

I am confused. You note the prior surgeries are an L4-5 ADR (artificial disc replacement) and an L5-S1 fusion. You then note you have left sided pain but don’t note the location (lower back, off to one side, sacroiliac, buttocks, leg) to quality of pain (standing, sitting, loading, flexion vs. extension).

If you had a fusion of L5-S1 and it is solid, this unilateral pars fracture should not be a pain generator if it is mechanical pain. If the pain is radicular in nature (see website) due to lateral recess stenosis and you have a solid fusion, all you would need is a lateral recess decompression.

If your fusion is not solid and you have that left sided pars fracture, this could be your pain generator. Do you know through a CT scan that your fusion is solid?

I had to remove your image sources as this is an anonymous site and you have identifying marks on your images.

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

May 12, 2015 at 7:08 pm

Post count: 16

#19458

OK, thanks for removing them. My pain generally is localized to the left side lower back. It is there all the time, it has been there noticeably for about 3 years. Did you take a look at the links at all or just remove them? Sometimes i get it in my leg depending on how much i move. Obviously, doing more of anything makes it worse. Sometimes the muscle bulges in that area, sometimes aches alot, depends.

Before my surgery, i couldn’t walk or run on this left leg. After surgery, it’s gotten better, but still get symptoms occasionally, depending on how i move. It’ hard to explain, all i know is, the issue stems from an area no more than 2 inches by inches on my left lower back.

Right after the surgery, i knew something was wrong. To the left of my lower back, My pain levels were extreme in that area. with terribly painful sciatica all the way done to my left foot. My right lower back had none of that going on. Since then, it’s been chronic pain there and won’t go away.

You think the distraction caused the pars defect to open back up? Here are a couple CT scans of the pars defect taken 2 months before surgery:

Dr. Coreman..does it look like that the L5 nerve root on the left is being trapped by the pars defect? And that could explain my left-sided symptoms? If i have had this fracture most of my life, couldn’t it be arthritic, since it’s essentially a joint? Why do you believe a pars defect repair is not necessary? You have stated that the anterior approach is not your first choice for this, and posterior support would be better? By decompression, you mean a laminectomy correct? Why cut anything out, if it can repaired give additional support?

bwink23
Participant

May 12, 2015 at 7:29 pm

Post count: 16

#19462

I have not done an updated CT scan yet to check the fusion site for a solid fusion. But i am not convinced the fusion even, if solid, will take care of this. It’s been a year and 3 months, and it should have formed a strong fusion by now…but i guarantee the work done on my back didn’t cause the amount of sciatica into my foot, it was like lightening bolts going into my foot. I have reason to believe that fracture is pinching my nerve root, and it sure looks that way on my old CT scans. The localized pain on my left lower back, what else can it be? I have no DDD, My facets look good on an MRI, i had facet injections done that gave no noticeable relief. I have read that the fractured ends a pars can become innervated, and they need to be cleaned out with a bone graft put in place to achieve a fusion.
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Donald Corenman, MD, DC

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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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