Pros and Cons of 2nd ACDF at different level within 6 months

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jmcdaniel61
Participant

January 29, 2015 at 3:58 am

Post count: 3

#12106

Hi Dr. Corenman,

Some brief details. Left shoulder and tricep pain with along with tingling down palm side of forearm with tingling in pinkie and and ring finger of left hand; onset early April 2014. MRI in May 2014. Results were:

C2-C3: Unremarkable.
C3-C4: There is a small disc bulge and anterior endplate osteophyte formation detected. There is effacement of the ventral thecal sac and mild bilateral neural foraminal narrowing. No evidence of spinal stenosis.

C4-C5: There is a focal midline disc herniation superimposed on an underlying broad-based posterior disc bulge. Endplate osteophyte formation and mild facet arthropathy detected. There is slight grade I retrolisthesis. The findings result in effacement of the ventral thecal sac, mild spinal stenosis and moderate to severe bilateral neural foramina!narrowing. No evidence of cord compression or cord signal abnormality.

C5-C6: There is mild facet arthropathy and slight grade I retrolisthesis. There is a broad-based posterior disc bulge and small endplate osteophyte formation detected. The findings result in effacement of the ventral thecal sac, mild spinal stenosis and severe left and moderate right neural foramina!narrowing. There is no evidence of cord compression or cord signal abnormality.

C6-C7: There is slight grade I retrolisthesis. There is a broad-based posterior disc bulge and endplate osteophyte formation detected. There is mild facet arthropathy. There is effacement of the ventral
thecal sac and moderate to severe bilateral neural foramina!narrowing. No evidence of spinal stenosis.

C7-Tl: Unremarkable.

Tried cervical steroid shot. Absolutely no relief. Neurosurgeon recommended ACDF C6 C7. Got a 2nd opinion from a Orthopedic Spine Specialist and he recommended a three level ACDF C4-C7. Consulted with neurosurgeon and he commented that I didn’t have any symptoms related to the other levels; might have in 2 years or 10 years or never. Worth avoiding multilevel for now. Had ACDF for C6-C7 September 2014. And IT WAS WONDERFUL. Absolutely pain and tingling free since late September.

Well, now it’s January. New pain started January 12, 2015. Still mostly left side. Feels like I’ve been punched in the arm. Pain on top side of forearm with tingling in almost all fingers though mostly middle and index fingers with thumb to a somewhat lesser extent. Arm pain is a 5-6; forearm pain is a 3-5. Pain is worse this time around as compared to last year. Contacted neurosurgeon and he wanted a new MRI, results below (Radiologist had access to both MRIs):

C2-C3: Unremarkable.

C3-C4: Again seen is a small disc bulge and anterior endplate osteophyte formation. There is mild effacement of the ventral thecal sac and mild bilateral neural foramina!narrowing. No evidence of spinal stenosis.

C4-C5: Again seen is a focal midline disc herniation superimposed on an underlying broad-based posterior disc bulge. Endplate osteophyte formation and mild facet arthropathy detected. There is slight grade I retrolisthesis. The findings result in effacement of the ventral thecal sac, mild spinal stenosis and moderate to severe bilateral neural foraminal narrowing. No evidence of cord compression or cord signal abnormality.

C5-C6: Again seen is mild facet arthropathy and grade I retrolisthesis. There is a broad-based posterior disc bulge and endplate osteophyte formation slightly more pronounced when compared to the prior examination. The findings result in effacement of the ventral thecal sac, mild spinal stenosis and severe bilateral neural foramina} narrowing. There is no evidence of cord compression or cord signal abnormality.

C6-C7: There is evidence of anterior cervical discectomy and fusion. There is good decompression of the canal without evidence of recurrent disc herniation or spinal stenosis.

C7-Tl: Unremarkable.

I see my neurosurgeon shortly. I’m guessing I should have had the multilevel ACDF back in September, but hindsight is always 20-20 and I was happy with the decision making process back then. Given the situation at C5-C6 has worsened a bit, I’m probably looking at another ACDF.

My question(s):

– what are the pros and cons of a 2nd ACDF?
– pros and cons within a small amount of elapsed time from the 1st ACDF
– given my symptoms, I long can I wait before having the 2nd ACDF without causing any permanent damage?
– should I look at another single level ACDF at C5-C6 or should C4-C5 be included as well?
– any options you can think of?
– anything else I should be considering / thinking about?

Like everyone else here, enjoy your website. Your YouTube video of an ACDF was very helpful as I was considering the 1st ACDF.

Sincerely,

John

Donald Corenman, MD, DC
Moderator

January 29, 2015 at 9:02 am

Post count: 8660

#12108

Your current symptoms certainly sound like a C6 radiculopathy (see symptoms of cervical nerve injuries on the website). There was no right or wrong answer to the initial question of how many levels needed an operation. If you only had symptoms of the C7 nerve, then regardless of how significant the foraminal narrowing was above this level, a one level ACDF is an acceptable decision.

The opposite tact can be taken. The levels above were so severely narrowed that you could have chosen a three level surgery to prevent the levels above from being pain generators. This is unfortunatly what actually happened to you.

Interestingly, you still can make the argument that you should only fix the C5-6 level as it is the only painful level and leave C4-5 alone. You run the risk of that level also one day being a pain generator (“moderate to severe bilateral neural foraminal narrowing”). Again, there are surgeons who would only do the C5-6 level and others that would do both levels.

In my hands, I look at the amount of compression present, how degenerative the disc above is, the alignment (amount of kyphosis present) and how much motion this segment has (off of the flexion/extension films). I then share this information with the patient and we make a decision together.

There is nothing that will get in your way if you have another surgery at an adjacent level in your cervical spine “so soon”. You should do just fine.

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.

jmcdaniel61
Participant

January 29, 2015 at 8:51 pm

Post count: 3

#12110

Thank you for the quick reply as well as your thoughtful comments. I especially appreciate your thoughts on whether to have a single-level or a two -level ACDF this time around. I don’t have any procedure concerns as the first one I thought was successful and was also fairly easy to manage. I’m also grateful for your comments on two ACDF procedures in such a short timeframe. That may have been my biggest concern.

With much appreciation,

John

Donald Corenman, MD, DC
Moderator

January 29, 2015 at 10:05 pm

Post count: 8660

#12112

Please keep us informed of your progress.

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.

jmcdaniel61
Participant

April 1, 2015 at 11:03 am

Post count: 3

#17760

So, I lucked out, I think. My neurosurgeon took a look at the new MRI and said the symptoms shouldn’t be coming from the neck (he said if I had any new problems it looked like it should be occuring on the right side, which isn’t sympotomatic). He thought I might have a nerve issue somewhere in the left arm. Prescribed a round of oral steroids. Took about two weeks, but I’m now (again) pain and tingle free on the left side. Gotta say it pays to listen to your doctor…

Now if medical science had a permanent solution to my lumbar facet joint arthritis I’d be really happy!

John
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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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