Pars Interarticulas fracture-L5

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bitmerkle
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April 25, 2013 at 1:05 am

Post count: 4

#8497

HI.
I’m writing because I am completely frustrated and in need of some advice. I grew up playing soccer, running, triathlete,etc..I had a compression fracture when I was 14, and continued with my active lifestyle. I have always had lower back pain, but always “played” through the pain. Now, at 35, about 8 weeks ago, the pain got sooo bad that I was not sleeping, sciatica pain when I ran, stopped all exercising and can’t walk for more than 1/4 mile without excruciating lower back pain. I am in boulder and currently seeing a doctor who ordered xrays (nothing), MRI-showing the Pars Interacticulas fracture-L5. He then ordered a bone scan and all he told me was that it was an old fracture (cold). He then offered steroid shots into my back. This was two weeks ago(i believe on the sides in the narrowing) both sides. It did not help at all. During that procedure he noticed an extra vertebrae. He said there is nothing he can do for that…He has now ordered another injection today on L3, L4, L5 and S? , MBBS.(the RX reads like that.)

I have been in so much pain for almost two months now and I don’t think these injections will work either. I can’t do anything without pain. No normal activities let alone exercising. Is there something else that can be offered? What are your thoughts? I’m thinking of going to see a nuerosurgeon….in boulder? Is there a surgery option? I’m over this pain!!!!!!!!

Donald Corenman, MD, DC
Moderator

April 25, 2013 at 4:21 am

Post count: 8660

#8500

A pars fracture of L5 occurs typically in about 5% of the population. See the section under isthmic spondylolisthesis under lumbar spine. Also typical is the ability to tolerate the back pain this fracture generates until one of two things happen. Either the disc at L5-S1 will disintegrate and the patient will develop significant lower back pain or the L5 vertebral body will collapse on the L5 nerve roots and leg pain will occur.

The injections you underwent were appropriate as some patients can improve from these. The MBBS was probably medial branch blocks, an injection used to see if you were a candidate for facet rhizotomies (see the section under facet injections). These are not typically very effective for this diagnosis.

Surgery is normally very successful for this disorder. See the section under TLIF to understand what surgeries can be used to alleviate the pain and stabilize this slip.

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.

bitmerkle
Member

April 25, 2013 at 10:41 pm

Post count: 4

#8503

Thank you, Dr. Corenman for getting back to me so quickly.

I do have a question though. Are you saying that surgery would only be an option if I had some disc problem in my back and if the vertebral body collapses on the L5 nerve roots that is causing the pain? I had my shots yesterday as explained in my previous email yesterday. he told me the most important thing to note is the first 24 hours to see if any pain goes away 70-80% then he would do the facet rhizotomies..So far, nothing has improved?…
My question is why if I have an L5 fracture that is clearly NOT healing for over 20 years, can’t we fix it now? Something is causing this pain and I’m tired of the PT, the steriod shots, the brace, the not being able to do any day to day activities. How long should I wait to see if these shots I got yesterday should work before contacting a neuro?

How likely is surgery for me with just the info I gave you?
Thanks for you time.

texasspondy
Member

April 27, 2013 at 5:01 am

Post count: 25

#8514

Bitmerkle, have you read the literature on Dr. Corenman’s site, it’s very useful info on spondy.
I’m not answering for Dr. Corenman by any means, but I also have l5 pars fracture, bilateral. My fracture is also very old, since I’m 42 now and it probably happened around 15 years old I believe. The bottom line is, is somewhat healed itself over the years by scarring up. So you and I have pannus or scar/bony tissue that is holding that lower pars joint together.
You can get it fixed now, with surgery, more than likely a TLIF, fusion. That is my option too. My pain is from muscle fatigue, 24/7 the low back muscles spasm from trying to hold that joint together. I work out and try to keep the low back strong without overdoing it but, honestly anything much more than sedentiary lifestyle will overwork the low back. I’m trying to deal with it as long as I can before I give in to surgery, due to the task that surgery will impose on ones personal life, job, finances, etc.
I have changed my profession from a physically demanding mechanic job to an office job, as well as modifying my habits, like bending over, I bend down, etc.

I hope this helps some and you can get some relief. The shots, did nothing for me, corisone, epidurals, nothing. Trigger point injections helped calm the muscles down but that’s just a temporary bandaid, at least in my case.

Donald Corenman, MD, DC
Moderator

April 27, 2013 at 10:28 pm

Post count: 8660

#8517

It is my opinion that the facet injections were not going to work in the first place. The painful disorder is not facet mediated. In fact, the L5-S1 facets are “disconnected” from loading in the first place. The original pars fractures have disconnected these facets. During surgery, when these disconnected facets are removed, they are normally pristine as these facets had not been loaded since the pars fracture.

The injection will declare itself successful in the first three hours only. This is the period of time that the anesthetic agent is active (similar to the length of time the jaw is numb from the dentist office after an injection). Waiting any further length of time for relief negates the diagnostic window (see pain diary).

Surgery at this point will not “repair” the pars fracture. This presence of this fracture produces other degenerative changes that are irreversible such as degeneration of the disc space and the slip of L5 on S1. Also, eventual L5 nerve compression occurs due to the collapse of this segment. All of these changes precludes direct repair of the pars fracture.

The solution of pain produced by this degenerative segment is a TLIF fusion (see website). Success rate for this procedure approaches 90%.

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.

bitmerkle
Member

April 29, 2013 at 2:05 am

Post count: 4

#8530

Thank you again, for your reply.
I wanted to give you my “direct report” from the MRI to see with all my pain that I’m having, symptoms that I would be a candidate for some sort of surgery? (TLIF). My concern is that my spine doctor who has been doing all of my injections said that there would be no option of surgery?? I just don’t understand? I can’t live like this much longer.

Okay, so here is the report. Let me know what your professional opinion would be
Findings: The vertebral bodies maintain normal height and alignment. Small foci of bright T1 and T2 signal within the L2 and L3 vertebral bodies corresponding with hemangiomas or focal fat are noted. Bone marrow signal is otherwise w/in normal limits. The conus ends at L1. No evidence of of arachnoiditis. The paraspinal soft tissues are normal.
T11-L4 – No annular buldge, central canal narrowing, or neural foraminal narrowing

L4-L5 Mild annular bulge without central canal narrowing, minor bilateral neural foramina narrowing .

L5-S1- Mild annual bulge without central canal narrowing. Mild bilateral neural foraminal narrowing. A left L5 pars defect is noted on sagittal image 12 w/out marrow edema. The right L5 pars interatricularis is elongated although appears intact. Mild bilateral facet arthropathy.

Impression: 1. Left L5 pars defect w/out marrow edema. Elongation of the right L5 pars interarticularis is intact. mild bilateral facet arthropathy and neural foraminal narrowing at L5-S1. No significant spondylotisthesis or degenerative disc disease at L5-S1.
2. No Disc herniation or central canal narrowing throughout the lumbar spine.

I have been inactive for 9 weeks now, have had all but the ESI injections, a brace on and the spine doctor doesn’t know what to recommend now? With these findings, would TLIF truly be an option or am I stuck with this pain forever?

Thanks again! Sorry to keep bothering you with these questions.
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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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