Post-Dual Lumbar Foraminotomy Symptoms

Tagged: herniated disc, sciatica, Spondylolisthesis

Viewing 5 posts - 1 through 5 (of 5 total)

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smeal4128
Participant

December 3, 2020 at 12:52 pm

Post count: 3

#33436

Dr. Corenman:

First off, thank you for being such a great resource to those of us suffering from some of these awful conditions.

To provide some context, I am 25 and have had sciatic pain (more-so irritation) since about 20 or 21. As a former multi-sport athlete in HS and powerlifter, my symptoms progressed which interfered with my workouts. I was diagnosed with a herniated disc at L4/L5 in 2016 and proceeded with conservative treatment. For the next 3-4 years, I tried to train as best I could and do core strengthening, my symptoms improved but I was never able to fully return to lifting without flaring up the nerve. Keep in mind, I was never bedridden with my sciatica and very seldomly had a shooting pain (maybe 7 or 8 times total). I essentially figured I would be stuck with minor nerve irritation on/ off and would never get back to 100%.

Whilst doing light deadlifts in March, I noticed I began developing S1 nerve root numbness in my outermost toes, the same side as the glute/ hip inflammation that I’d be dealing with for years. I scheduled an appointment with a new nuero with the following update MRI and x-ray:

IMPRESSION:
Increasing size to L4-5 disc herniation compared to previous. No significant spinal canal or foraminal stenosis.

Spondylolysis and stable grade 1 anterolisthesis L5-S1. Disc bulge
Narrative
INDICATION:
Low back pain, lumbar radiculopathy.

COMPARISON:
2016

TECHNIQUE:
Sagittal, axial, T1 and T2 sequences were performed without contrast. The exam was performed on 1.5 tesla closed high field MRI

FINDINGS:
The lumbar vertebrae show no evidence of acute fracture. The conus terminates at L1. Reporting assumes 5 lumbar vertebra.

L1-2 disc space shows no evidence of canal or foraminal stenosis. There is no acute finding.

L2-3 disc space shows no evidence of canal or foraminal stenosis. There is no acute finding.

L3-4 disc space shows no evidence of canal or foraminal stenosis. There is no acute finding.

L4-5 disc space shows disc space narrowing disc bulge and central disc herniation more prominent compared to prior study. It abuts the thecal sac but does not cause any significant canal stenosis.

L5-S1 disc space shows no evidence of canal or foraminal stenosis. There is no acute finding. There is mild disc bulge. Grade 1 anterolisthesis is stable at L5-S1. Findings of bilateral spondylolysis are again noted.

XRAY:

Impression
IMPRESSION:
L5 spondylolysis with L5/S1 spondylolisthesis.

1.4 mm increase in spondylolisthesis with lumbar extension.
Narrative
INDICATION:
Low back pain, lumbar radiculopathy

COMPARISON:
MRI lumbar spine 07/13/2016

TECHNIQUE:
Four views lumbar spine

FINDINGS:
On the lateral neutral view, L5/S1 spondylolisthesis measures 4.6 mm. L5 spondylolysis. With flexion, the spondylolisthesis measures 5.2 mm and with extension 6.1 mm. The intervertebral disc heights are otherwise normal. No compression fractures.

Also worth noting, I was making the best progress in years by fixing my deadlift form with almost a complete resolution of symptoms (I deadlifted 2 days before surgery). However, symptoms were still intermittent and I figured I wouldn’t be able to get back to 100% since there was clearly something impinging so I went ahead with surgery. Also of note, I’ve almost never had backpain and any discomfort was fixed by strengthening my core/ deadlifts.

On September 28th, I had surgery for the doc to look at the disc and see what the best course of decompression would be. He did dual left-side foraminotomies at L4/L5 and L5/S1, noting that the disc was ‘calloused over’ and he didn’t think it should be messed with since it was clear that two bone spurs were causing my issues.

I’ve had a somewhat slow recovery so far, but have noticed days of solid improvement. I’ve been taking ibuprofen on and off with flare ups (currently dealing with somewhat significant inflammation 9.5 weeks post-op.

Are these flare-ups typical? Should I run an oral steroid cycle as I continue to increase my activity?

It seems as though the spondylolisthesis was an incidental finding. If the flare ups stop happening and I return to 100%, would you recommended that it’s safe enough to return to lifting/ athletic lifestyle?

Please let me know if you need me to clarify anything. I want to thank you in advance for any insight that you may have into my condition.

smeal4128
Participant

December 6, 2020 at 12:21 pm

Post count: 3

#33447

Dr.Corenman, please let me know if there is anything you would like me to clarify. I look forward to your insight into my issue – thank you in advance.

Donald Corenman, MD, DC
Moderator

December 8, 2020 at 10:01 am

Post count: 8660

#33452

First, stop deadlifts. The amount of shear forces on a bad disc are not helpful and can lead to significant problems. Especially with an isthmic spondylolisthesis, deadlifts and squats are contraindicated. Your disc above the slip (L4-5) is breaking down (“Increasing size to L4-5 disc herniation compared to previous”) which is non descriptive as to nerve root compression.

It would be unusual to have an S1 nerve root involvement in your case as the isthmic spondylolisthesis at L5-S1 would compress the L5 root typically in the foramen and the L4-5 herniation would also compress the L5 root and not typically the S1 root.

You note; “On September 28th, I had surgery for the doc to look at the disc and see what the best course of decompression would be. He did dual left-side foraminotomies at L4/L5 and L5/S1, noting that the disc was ‘calloused over’ and he didn’t think it should be messed with since it was clear that two bone spurs were causing my issues”. Generally, in the face of an isthmic spondylolisthesis, it is problematic to do a decompression at that slip level as the minimal stability of the slip can be disrupted.

You should probably become involved with a Pilates core strengthening program to stabilize your slip level.

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.

smeal4128
Participant

December 8, 2020 at 2:41 pm

Post count: 3

#33455

Thank you for your response, I appreciate it, Dr. Corenman. I will certainly refrain from deadlifts and squats to prevent any further trauma to the L4/L5 disc.

My surgeon noted that the disc was not compressing the nerve and did not need to be removed. He did mentioned that there was a large bone spur at L5 and a smaller one at S1.

I have never really had back pain and the surgeon believes that the slip finding is incidental since the lesion is stable. Are you interpreting that the slip is unstable?

Should I expect my sciatica symptoms to continue to improve? As I mentioned, I was pain free for about 2 or so weeks, until I started PT and doing adduction and abduction exercises. I am again noticing irritation start to subside with no PT and just walking as therapy.

Thank you so much.

Donald Corenman, MD, DC
Moderator

December 8, 2020 at 4:00 pm

Post count: 8660

#33456

Since this level has slipped, this means the disc is failing slowly which is the only intact structure that instills stability. The spurs he removed always develop in a slip due to the bodies attempted repair of the pars fracture that never heals. Hopefully you will continue to improve and this will be a non-issue.

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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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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