[CPG890]

#22369

Dear Dr. Corenman,

I am writing with a couple of questions that I hope you may be able to shed a little light on. I am a 37 yr old male in good health with avg weight and height. I had a grade-one congenital spondylolisthesis at L5 with DDD at L4 and L5. I had right leg pain and broad sciatic pains and lumbar back pain at the location of L5 specifically. I also suffered with neck and thoracic muscle spasm pain, as it seemed my body was overcompensating to take pressure off of the lumbar spondy problem. All of these symptoms together made me decide to have surgery as I had been suffering for 14 years and it was only getting worse over time. I had the surgery at Emory with a very experienced and well-respected orthopedic spine surgeon.

I am four months post-op from a two-level ALIF (L4-S1) using stand-alone titanium cages packed with BMP. Additional fixation at L5-S1 only using anterior plate with four screws was done to add stability due to the spondylolisthesis. No posterior surgery was performed. Right after surgery, I noticed a lot of clicking and cracking and movement of the posterior elements of the spine at L5-S1- similar to my pre-op symptoms. I was told this would eventually subside. I did not have leg pains anymore right after surgery but about three weeks after surgery I developed a return of the right leg pain (similar to pre-op symptom). It started getting worse, then, leveled out, and then slowly got better but I still have a slight tightness behind my right knee. Of equal concern, I am experiencing grinding, clicking and popping sensations at L5 only, bi-laterally but mostly on the right side pars/joint, which is associated with a feeling of pressure in my back making me feel like I want to “pop” a joint, much like cracking a knuckle. The grinding and clicking sensation and sound is not really associated with leg pain anymore (just slight tightness in right leg), but, it is associated with a return of the muscle tightness/spams in my neck, shoulders and down the thoracic area. The muscle pain really hurts as if I am in a “pre-spasm” state all the time.

I read a thread with your opinion favoring TLIF over ALIF for Isthmic Spondylolisthesis for the exact reason of addressing the pars-defect as you have observed in some patients continued leg-pain despite a solid fusion. I can’t go back and undo the ALIF I had, but, assuming I get a solid fusion at both levels, would it be appropriate to have a foraminotomy at L5 to deal with the pars-defect? Would it make sense to have a bi-lateral foraminotomy or just the one side that is bothering me? Is it too soon to be thinking about this and is is possible that the right leg pain/tightness and muscle tightness in my neck/shoulders will go away once sold fusion is achieved?

I sincerely appreciate your feedback!
Very best,
Paul

[Donald Corenman, MD, DC]

#22382

Generally, ALIF (anterior lumbar interbody fusion) needs a backup for stabilization as this construct is not that stable by itself. Anterior fixation is not as strong or as stable as posterior fixation so that is why most ALIF surgeons will place pedicle screws posteriorly to “shore up” the structure.

The reason that the surgeon said “give it time” is that he was expecting the fusion to “take” and reduce motion of the posterior structures. 4 months out from a fusion with continued “popping and clicking” makes me think the fusion is not taking and might have to be further addressed surgically. Typically, I like to wait 6 months and then get a CT scan to determine if fusion has a chance of occurring.

If you do get a solid fusion, then a partial pars removal (only on the side of symptoms) is the typical surgical procedure to decompress the root (if there is continued leg pain. The popping and clicking is more worrisome for non-fusion however.

Tightness in the neck and shoulders certainly could originate from the delayed union at the surgical level but could be independent and from another pathology altogether. A thorough workup would be indicated to determine the source of the symptoms.

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.

[CPG890]

#22394

Dr. Corenman,

I appreciate the thoughtful response. Your patients are lucky to have you.

Paul

[CPG890]

#22829

Dr. Corenman,

I am the original poster of this thread and I am getting back with an update and a question for you. It has been over six months (operation was Feb 1st) since my two-level stand-alone ALIF (L4-S1) with anterior plate at L5/S1 to fix the grade-one isthmic spondylolisthesis at L5/S1 and degenerative disk at L4. Put simply, things are not going well. I have continued back pain coming from, what I think is L5/S1, where I feel the pars defect rubbing and clicking. The L4 area does not hurt.

My surgeon is quite sure I did not fuse at L5/S1 but L4 is unclear. He wants a CT Scan to evaluate fusion and also an MRI (maybe with contrast to see neuroanatomy) and said that if I am not fused, a posterior gutter fusion with pedicle screws would be appropriate. He is hoping that L4 is indeed fused and that the posterior gutter fusion would just need to be performed on L5/S1 where the spondy/pars defect is. The positive is that I have no neurological deficits at this time. I do have considerable back pain which feels mechanical in nature and results in moderately/severe sciatica episodes if I do too much and irritate the nerve roots.

I am in the process of having these tests completed in the next few weeks. My question to you is: Do you offer paid phone consultations and/or second opinions to patients that are not local? This forum is wonderful and you have been so helpful thus far, but, I would like to have you evaluate my case specifically with all the necessary imaging studies and speak with you formally as to where I go from here.

Thanks again for your time,
CPG

[Donald Corenman, MD, DC]

#22831

If your L5-S1 did not fuse, then a posterior fusion would be the next step. You would probably need a decompression of the side of your intermittent leg pain. The fusion needs to be between the transverse processes of L5 and the ala of the sacrum as a fusion mass of the lamina will do no good (the lamina is disconnected from the pedicles of L5).

I do offer a service called a “long distance consult”. You would fill out all the paperwork just like an in-office patient would and send all your images (both before and after surgery including X-rays, CT scans and MRIs). All the previous physician’s office notes would be helpful but I understand if those cannot be procured. I go through all the images and then call you directly. We typically spend about 20-30 minutes on the phone and I give you my conclusions both verbally and by dictated note. If you eventually come out to be seen in-person, the office visit is reduced and much easier to understand and go through. The plan, if surgery is needed is very commonly the same plan that is discussed over the phone with rare exceptions.

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.

[CPG890]

#23523

Dear Dr. Corenman,

I am writing to followup with you. A lot has happened since we last corresponded. I have some new information and also some problems that are perplexing and remain unresolved. I will summarize very briefly my history including surgical interventions, diagnostic tests and the remaining issue that persists.

In Feb 2016, I had a 2-level ALIF, which according to a CT scan in September 2016 has confirmed solid fusion at L4 through S1. I had two orthopedic spine surgeons assess the CT scan and their opinions converged; solid fusion. Despite the solid fusion, I had residual right leg pain down my hamstring, behind my knee, and sometimes into my my foot that never went away. I had a feeling of micro-movement at L5 with clicking and cracking and grinding sensations at L5, particularly on the center to right side. My surgeon then suggested to do a diagnostic anesthetic/steroid injection into the pars defects bi-laterally at L5 to see if that might be the source of residual pain. Paying attention to the first few hours after the injection, I noticed a great reduction of pain. The natural conclusion was the remaining pars defect was causing sciatic irritation and the “Gill” fragments should be removed.

On November 28th, I had a bi-lateral Gill Laminectomy and bi-lateral Foraminotomy performed at L5. The ligamentum flavum was also released at L5 and L4. He removed the “alange” of the S1 lamina bi-laterally for the equivalent of an S1 laminectomy. My surgeon indicated there was some degree of foraminanl stenosis and flattening of the nerve root of L5 on the right-hand side. In the end, he indicated the nerve roots were fully and completed decompressed on both sides.

The problem I face now is that I still feel right leg pain in the same spot as described above. In addition, I feel a pinching feeling on the right side at L5 and a mechanical popping or clicking or grinding feeling that seems to correlate 100% with my right leg pain. At the very least, it attenuates the quality of the pain I feel and my tendency is to want to contort my body to “get off the nerve” as if to apply a traction effect.” The worst position for me to be in is sitting.

The laminectomy/foraminotomy surgery did seem to help my general sciatic pains which cleared up in about one week post-op. However, this right leg pain is persistent and the sensation of micro-movement or a mechanical problem at the right L5 side is disconcerting and I feel it is related in some way to my leg pain. I am simply at a loss as to what do to. What structure is left in my spine that could be causing my leg pain and this mechanical grinding sensation? My surgeon said unequivocally that the decompression was fully successful with no complications or issues encountered.

I recognize that perhaps total resolution of leg pain is too much to ask for only being two weeks out from surgery. But, I am just attached to the idea that something is wrong because of the mechanical sensation I have in my spine at the area that seems related to the leg symptoms. Sometimes when the L5 right-side joint “pops” the leg pain subsides. It usually happens when I am laying on my back in bed and I just squeeze my right glute muscle, it pops. In my mind, this suggests that there isn’t permanent nerve damage but rather there is still something pinching my nerve root which makes me pessimistic that my symptoms are just related to surgical swelling and will go away with time. Any light you can shed on this or advice is so very much appreciated.

Thank you.
Paul

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