[Jtal19305]

#20960

Hello dr Corenman

I have done a lot of on line searches and read many medical articles regarding back surgery. My case was a posterior laminectomy of t12 l1 with removal of the disc and implantation of a interbody cage. Instrumentation in the form of pedicle screws and rods were added between t12 and l1. I believe the facet joints were removed.

I do not see much on line similar to the surgery that was performed on me to decompress my cord. I wonder if this approach is a standard or acceptable approach to deal with compression and bone spurs at that level?

I know you stated that you prefer instrumentation at that level. Was it necessary for me to have the laminectomy or could the disc herniation and bone spurs be removed without having to remove the lamina. I realize my operation was not the standard lower back type. Im concerned because I have read articles that have said surgeons have abandoned thoracic laminectomies due to the poor outcomes and neurological deficits. I don’t know if this applies still. And I wonder if the surgical approach is causing my left leg and foot nerve pain that I have had since surgery?

Thanks
Jerry

[Donald Corenman, MD, DC]

#20982

Thoracic laminectomies by themselves without fusion have generally poorer outcomes but are still great procedures in the right cases. Since the thoracic spine is naturally in kyphosis, the posterior structures are under tension. That is, the spinous processes and the ligaments associated “hold” the position of spine from bending further forward.

If you perform a thoracic laminectomy, you remove those tethers and the spine can start to bend forward even more. This is why a fusion is generally a good idea to prevent this forward bend from happening. In addition, if anything else could occur at this previously operated site (more bone spur, recurrent disc herniation), revision surgery is fraught with potential complications. Again, fusion prevents further problems.

If the canal is narrowed by posterior structures (hypertrophic ligamentum flavum, degenerative facets), the thoracic laminectomy with a fusion is a good procedure.If the canal is narrowed by a disc herniation, the laminectomy is only part of the procedure but performed to allow the cord some increased room while the lateral portion of the procedure is performed.

I can’t tell you if the procedure caused your left leg pain but it would make some sense as the TLIF was performed on the left side.

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.

[Jtal19305]

#20984

Hi Dr Corenman

Your explanation makes a lot of sense. I know that I had a disc bulge with bone spurs from the back (behind the thecal sac) that were not removed at T12/L1. I’m not sure why hey we’re not removed. Probably because the doctor did one approach from the posterior side and did not want to retract the cord to get to the Spurs. He may of felt it was not necessary since he removed all the lamina and other bone for the laminectomy. I know in his surgical report he did not call it a TLIF. I have a single incision down the middle of my spine for the T12/L1 procedures that is about 5 to 6 inches long. Then I have a much smaller 1 inch incision offset to the left slightly for the L23 hemi laminectomy.

Like I said I awoke with a burning pain in the sole of my left foot. This pain is still present but is less than right after surgery. I also still have calf fasiculations from time to time.

I’m trying to get an appointment with a major doctor at the university of Miami to have me checked out again. I’m afraid I cannot get objective diagnosis from my current doctor. My current doctor insists he did not have to touch or retract the cord to get the fusion cage in. He wants to order a new MRI. If I get into Miami, they may have their own set of diagnostics for my case. I just hear that most back surgery patients are better after about three months. I’m going on six months so this is why I’m concerned about my condition. I have the burning pain in my left foot still and pain and numbness in my left outer thigh. I also get pain in my calves. I just want to make sure nothing else can be done to help me. I am really at the mercy of the doctors now. I’m desperate to get better. I don’t want necessarily want another surgery unless their is complete consensus and the benefits are worth the risks.

Thanks for all of your insights
Jerry

[Jtal19305]

#20985

Hi I forgot to ask is it possible or advisable that the instrumentation be removed from my spine at some point in the future. I imagine once the bone fusion is complete the rods and screws serves no other purpose? I understand many doctors advise to leave the hardware in as more surgery could imply more risk. I was just wondering if it is possible to remove it without jeopardizing any structural support.

Also, if for some reason the bone spurs must be removed by an approach for the side of my body, would the hardware present a barrier? I understand the Spurs form as the body’s own defense against instability. So if the spine is stabilized by the fusion, will the Spurs dissolve or soften over time as they are no longer needed? How difficult of a procedure is it to remove the Spurs at this point?

Again I’m hoping the Univ of Miami spine center will agree to see me. They have indicated they would but I have yet to have an appointment. So far my own doctor and an outside expert found my case to be interesting enough to present it to their peers or students. I wonder if my case may not become one for study purposes that could be published like so many I have read on line.

I was so healthy before all this surgery. I am not going to give up finding out what happened to me and what can be done. My concern is that unnecesaary or inappropriate surgery was performed but even if so, if it was done right, I should heal and the nerve pain should resolve. If the independent expert I paid could find potential issues reviewing my MRIs in detail, I can’t see why my own doctor or hopefully the renowned neurological a surgeons at Univ of Miami can’t see them as well. I could not even get my own doctor to listen to me so this is why I’m seeking the experts at the Miami health (university level care).

Thanks
Jerry

[Jtal19305]

#20991

De Corenman

I know I’m getting ahead of you with a lot of questions but a things came to my mind reading your last post. You indicate another surgery at t12 l1 is fraught with complications, and you mention the lateral portion of the procedure to remove other compressive elements. Why is such a surgery fraught with complications ? If something else had to be done to further decompress, is the risk too great ?

In my case the surgeon did not remove the bone spurs and the protruding disc annulus is still encroaching the canal. I wish I could email you a photo of sag and axial views and you could see what I mean. My spinal cord or canal actually bends somewhat across t12 and l1 due to the protruding disc there. So it appears the surgeon only decompressed from the posterior side with a laminectomy. Yes he removed the disc (the jelly like material inside) but nothing else was removed such as the bone spurs or annulus. I’m not sure if that is normal for my kind of procedure. I did have one doctor comment about the slightly bending or kinking cord as not a good thing. This doctor recommened further surgery to remove the bend by jacking up the space between the vertabrae (distraction) and he even suggested that a partial corpectomy would be beneficial to remove the bone spurs and anulus on the back side of the cord which could be causing more compression. Somehow he said he could do the procedure in two stages in the same day. One to remove the hardware from behind, the other to use endoscopic approach from the left side for the partial corpectomy and then re-install the hardware. He was a younger surgeon who seeemd very confident. I was not too eager to have such a procedure performed this early after my original surgery. I have had other doctors suggest to do nothing and that the bone spurs were there before are probably not hurting anything.

So I’m left with a constant diffuse burning pain in my feet mainly on the left but can affect the right foot at times and the pain works into the calves again left side being worse but occasional pain on right side. The pain seems flat lined; I have better and worse days but never been quite pain free days. It’s been almost 6 months post surgery.

This is where I hope the medical professionals at Univ of Miami Miller school of medicine can look over my case and images and give me a definitive opinion. I don’t have a lot of faith in my current doctor. He did x rays for the spinal fusion follow up but I don’t believe you can confirm fusion from X-rays. Also the x rays seemed too bright, over exposed, so I don’t know how valuable they are. I’m not sure why he did the flex extension x rays with me laying down and he did not order a thin slice ct scan.

I hope I have better luck with the folks at Univ of Miami. They first want to review my images and case before they agree to take me on as a patient.

Thanks

[Jtal19305]

#21006

Dr Corenman

If you can, please read the study I the link on thoracic laminectomies. I would love to hear your comments.

http://www.medscape.com/viewarticle/405654_2

I am copying below the first couple of paragraphs of the article in the link above. Maybe you have read this before but I would like to hear your comments

Surgery for Thoracic Disc Disease. Complication Avoidance: Overview and Management
William E. Mccormick, M.D., Steven F. Will, M.D., and Edward C. Benzel, M.D., Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
Neurosurg Focus. 2000;9(4)

Table 2 provides a summary of surgery-related complications reported in clinical series between 1934 and 1998. Of note is the high rate of neurological deterioration seen in the earlier studies in which a thoracic laminectomy was used. Of the three patients reported in the earliest paper published, two developed paraplegia, and one died seven months after surgery.[19] In 1936, Hawk [10] reported four patients who similarly underwent thoracic laminectomy for disc herniation: two patients became paralyzed and two died. In other series conducted prior to 1960 similar results were demonstrated, with rates of neurological deterioration ranging from 24 to 75%.[11,15,16,21,32] The results of more recent studies have confirmed this bleak prognosis. In 1986, Lesoin, et al.,[14] reported 21 patients who underwent surgery for thoracic disc herniation. Of the three patients in whom a laminectomy was performed, two suffered postoperative neurological deterioration.

Several theories exist to explain the poor results associated with standard laminectomy approach. It is thought that the manipulation required for removal of the disc ventral to the spinal cord may produce mechanical injury and also potentially interfere with the spinal cord blood supply. There is also evidence that even minor kyphotic deformities produced by laminectomy can cause tethering of the spinal cord over incompletely removed disc or osteophyte and, in turn, lead to neurological deficit.[17]

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