Viewing 6 posts - 7 through 12 (of 20 total)
  • Author
    Posts
  • Donald Corenman, MD, DC
    Moderator
    Post count: 8656

    I would think that there still is adequate bone for the pars but there always is the potential threat of an iatrogenic pars fracture due to thinned pars being overloaded with activity. I think if the X-rays are clear and well done, the surgeon should be able to determine if there is enough bone left but sometimes, residual pars thickness is hard to determine on plain X-ray.

    A CT scan would give plenty of information but is generally only needed in specific situations. If the pars is too thinned, there generally does not need to be a call to fuse initially (the ultimate answer if the pars fractures). I would have the surgeon take as little bone as possible for the approach and just start normal rehabilitative activity afterwards. If the pars breaks unfortunately, that can be managed by a fusion if necessary.

    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.
    BillL
    Participant
    Post count: 18

    Thanks for the details as this is getting more complex. First post op with primary surgeon in a few days and will strongly consider second opinion from another surgeon comfortable with lateral access procedures and see if one of the two will order an updated MRI (insurance may place minimum post op parameters).

    Will update when more details and again all you said makes great sense.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8656

    Please keep us informed.

    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.
    BillL
    Participant
    Post count: 18

    Dr Corenman:
    Update: I saw the surgeon for the first post op visit today at about 4 weeks and 3 days. Symptoms continue. He was I little on the defensive side despite my symptom descriptions and questions being carefully and tactfully posed.

    At any rate he says during the surgery that he accessed the subligamentous fragments successfully. He recalled encountering what was apparently an extended fragment inside the formaninal area, presumably with some extending inside the lateral foramen. He thinks he found the medial edge of the existing annular tear/fissure but placed a more medial additional cruciate annulotomy a short distance away presumably for better access. The. Used an angled curette of sorts to push the extruded fragments back through the original tear, then retrieved them from within the annulus via his annulotomy.

    When I politely queries about more lateral elements he said he was confident that he “got it all” and that he probed all the way out through the foraminal passage with a very open and non obstructed nerve clearance. Even said that he wasn’t that impressed with the extraforaminal bulge and that many people with that don’t have direct or significant nerve root compression and are often asymptomatic.

    He said regeneration was always possible but didn’t seem to add much credence for some reason. Still says continued nerve root inflammation can go on for many weeks and that up to 3 months would not usually bother him in absence of motor weakness or debilitating pain.

    When I proved a bit more as to what IF there were residual or recurrent farther lateral issues, and potential approaches he seemed a bit annoyed. Basically said that he doesn’t like the lateral approaches although has done them in the past….said that in the extraforaminal location that the diesel sleeve is absent on the nerve root, and that the root and the annulus can appear almost identical causing high risk of nerve injury. This in addition to the statement that virtually breathing on the dorsal root ganglion can severely irritate that, causing even worse and prolonged pain.

    Finally, after probing a possible repeat MRI he said he favors wating 3 months post op. When I suggested that was longer than my comfort he acted though he would consider by 8 weeks post op if symptoms persist. Yet he also was surprised that a recent trial of NSAIDs and a MDP had little effect.

    At this juncture not sure what to make of this and which way to proceed. To further complicate issues, as you know, surgeons have this 90 day insurance “global” payment whereby must handle the post op issues for that time frame. Many local surgeons will not even see a patient post op until after these 90 days expire.

    Any additional insights Would be appreciated and thanks for your help thus far.

    BillL
    Participant
    Post count: 18

    Dr Corenman:
    Update: I saw the surgeon for the first post op visit today at about 4 weeks and 3 days. Symptoms continue. He was a little on the defensive side despite my symptom descriptions and questions being carefully and tactfully posed.

    At any rate he says during the surgery that he accessed the subligamentous fragments successfully. He recalled encountering what was apparently an extruded fragment inside the formaninal area, presumably with some extending inside the lateral foramen. He thinks he found the medial edge of the existing annular tear/fissure but placed a more medial additional cruciate annulotomy a short distance away presumably for better access. Then Used an angled curette of sorts to push the extruded fragments back through the original tear, then retrieved them from within the annulus via his annulotomy.

    When I politely queried about more lateral elements he said he was confident that he “got it all” and that he probed all the way out through the foraminal passage with a very open and non obstructed nerve clearance. Even said that he wasn’t that impressed with the extraforaminal bulge and that many people with that don’t have direct or significant nerve root compression and are often asymptomatic.

    He said reherniation was always possible but didn’t seem to add much credence for some reason. Still says continued nerve root inflammation can go on for many weeks and that up to 3 months would not usually bother him in absence of motor weakness or debilitating pain.

    When I probed a bit more as to IF there were residual or recurrent farther lateral issues, and potential approaches he seemed a bit annoyed. Basically said that he doesn’t like the lateral approaches although has done them in the past….said that in the extraforaminal location that the dural sleeve is absent on the nerve root, and that the root and the annulus can appear almost identical causing high risk of nerve injury. This in addition to the statement that virtually breathing on the dorsal root ganglion can severely irritate that, causing even worse and prolonged pain.

    Finally, after probing about a possible repeat MRI he said he favors waiting 3 months post op. When I suggested that was longer than my comfort he acted though he would consider by 8 weeks post op if symptoms persist. Yet he also was surprised that a recent trial of NSAIDs and a MDP had little effect.

    At this juncture not sure what to make of this and which way to proceed. To further complicate issues, as you know, surgeons have this 90 day insurance “global” payment whereby must handle the post op issues for that time frame. Many local surgeons will not even see a new patient post op until after these 90 days expire.

    Any additional insights Would be appreciated and thanks for your help thus far.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8656

    He is obviously uncomfortable with the far-lateral approach and I think “hopes” that the root inflammation will calm down over time. While it is possible to retrieve fragments that are foraminal by the medial approach, far-lateral fragments will generally not be affected by the indirect surgical method (trying to retrieve fragments from the inside-out approach).

    I think that a new MRI with gadolinium will not be harmful but can add significant amounts of information to your current situation. I understand he is “touchy” but he should be able to see that a new MRI is benign, does not comment on his technique, and can give much information on your current state.

    If a new MRI reveals a continued or recurrent far-lateral herniation, he will have to refer you to a colleague that is proficient in this technique. He probably does not want to consider referral at this point. Maybe a gentile coaxing would be in order?

    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.
Viewing 6 posts - 7 through 12 (of 20 total)
  • You must be logged in to reply to this topic.