Pars Fracture L4L5 after Microdiscectomy herniation surgery. Terrified of fusion

///Pars Fracture L4L5 after Microdiscectomy herniation surgery. Terrified of fusion
Pars Fracture L4L5 after Microdiscectomy herniation surgery. Terrified of fusion
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  • mstepanov3
    Post count: 1

    Hello, I have been reading through this forum for awhile and have gained much insight and knowledge. Thank you for all that you do!
    I really need your advice doctor.

    I am 28 year old Male and I have never had back pain in my life. All my discs were normal until this injury. I had a herniated disc due to lifting something heavy and had unbearable sciatica pain since(3 months). I elected to have a microdiscectomy surgery done May 2018. Follow up MRI one month after surgery shows a bulging disc(annular bulge) and mild narrowing of the spinal canal with no herniation. I also apparently have a developmentally small spinal canal.

    Since the surgery I had a complete reduction in my sciatica going down to my leg, instead now it stops around my butt area and into my thigh sometimes. I couldn’t stand for very long or walk longer than a block without unbearable pain until I had an epidural shot. I have no pain when I sit or sleep(some before epidural shot, now it’s zero).

    As of now I have pain standing for too long. I cant jump more than two times without significant pain. I cant do anything without pain short of sitting and sleeping. I can lift things without issue and hold them for short periods but not for long. No weakness. Sometimes I feel like my back muscle on the affected side is weaker. When I try to flex the muscle I have pain but It feels weaker. I wobble and keep most of my weight on my left( unaffected) side.

    I went to my surgeon with this information and he elected to have a CT scan. After reviewing the scan he thinks I have a pars fracture. I asked him if he could just do a revision surgery since i have a bulging disc(he says herniation). He says if he opens me up and sees a fracture he will give me a TILF fusion. If there is no fracture he will do a revision surgery. I told him I am only 28 and terrified of doing a fusion so young. Also afraid of Adjacent segment disease down the line.

    He had me do a whole body spect bone scan to rule out the fracture.

    The results of the bone scan say
    INDICATION: Herniated lumbar intervertebral disc and pars fracture at L4-L5 s/p microdiscectomy. Evaluation for osseous metastatic disease.
    There is a focal uptake at right L4-L5 pars interarticularis consistent stress fracture of the pars. Tracer distribution elsewhere is physiologic. Both kidneys are visualized.
    Focal uptake consistent with stress fracture of the L4-L5 pars interarticularis

    I have a pars fracture and a bulging disc in the same segment of the surgery. After these results the surgeon recommends a TILF fusion. I am trying to see if I can get a pars fracture repair instead of a fusion? If my disc has degenerated even a little, does that possibly make me a bad candidate for pars repair? if so, why? If the surgery is done anyways whats the worst that can happen? Can I do this surgery and then a fusion if it doesn’t work?

    How can we tell if the fracture healed? Maybe the pain is just coming from the “reherniated” “bulging” “annular bulge” disc since I have a developmentally small canal Maybe a revision surgery is all I need?

    Could this fracture have happened as a result of the microdiscectomy surgery?

    worth mentioning: there is no vertebral/disc slippage due to this fracture(yet)

    Thank you!!!!

    Donald Corenman, MD, DC
    Post count: 6578

    Pars fractures after microdisectomy can occur as the pars is thinned out when the laminotomy is performed. If the pars is thinned out too much, then the bone can fracture and cause what is really a facet fracture. Iatrogenic facet fractures (caused by previous surgery) generally cause local one-sided lower back pain and not buttock and thigh pain (although occasionally facet fractures can cause root irritation and buttocks pain). Since you have a narrowed canal, you probably have a narrowed pars which meant that the surgeon had to take more bone as a ratio of pars width to bone removal to open the canal since the opening from surgery has to be big enough to gain access to the canal.

    Unfortunately, if the pars was too thinned, a facet repair is probably not possible. There is not enough bone left to allow a repair and withstand the stresses of athletic activity. It might be a possibility that another microdiscectomy could help your symptoms but I think that is doubtful. Since you have already had one microdisectomy, have a recurrent herniation and a facet fracture, I would agree that a TLIF would be the correct response to this problem.

    I would not worry too much about the TLIF fusion. The chance of problems that can develop in an adjacent level leading to surgery in years to come is only 2.5% per year.

    Dr. Corenman

    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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