[Reasonable2012]

#7638

Hello, and thank you for your website. Am considering setting up an appointment with you folks; live in Fort Collins and only have the CICP (Colorado Indigent Care Program) for medical care.

1. Wondering if a car crash can cause adult male traumatic spondylolysis of L4-L5 and the subsequent cascade of degenerative conditions: => spondylolisthesis => severe stenosis => total disk degeneration? We hear a lot about whiplash of the neck, but wondering how common it is for traumatic spondylolysis to occur in a car crash that is capable of whiplash to the neck?

It seems reasonable to me (engineering background) that by having lower body restrained in a seatbelt and then experiencing violent forward deceleration (vehicle goes from 25-30mph to 0mph in perhaps 6 inches) and simultaneous violent sideways acceleration (vehicle pushed violently sideways about ten feet), that the shear forces involved could cause traumatic spondylolysis in a 51-year-old adult male.

You know, the upper body has momentum to continue forward while the lower body is stopped. The upper body wants to stay in place while the lower body moves sideways, and this all happens at the same moment. Seems reasonable such shear forces could make both pars snap.

Wondering if you have any info that quantifies the forces required in an event as an adult to make the pars interarticularis fracture on both sides. Even conjecture or anecdotal information would be helpful.

2. Also, in such an event, how likely is it that one would immediately be aware of the fracture? In my case, I was taking daily doses of Soma and Diclofenac for fibromyalgia-like full-body symptoms, which did in fact mask some other symptoms from the crash. Is the adult fracture of the pars typically quite painful, or is it able to go unnoticed? How long does it typically take before some figures out they have an adult injury to the pars? My doctors did not check for it at the time of the crash.

My reason for asking all this is that I aggravated my back in 2004 and an MRI (7 years earlier than the car crash) showed the disks were well-hydrated and healthy and no indication of spondylolysis or spondylolisthesis. Mild stenosis was all. A couple weeks of rest and I was good to go. I now have moderate to severe stenosis, about 17% spondylolisthesis, and spondylolysis. The disk looks totally black or “dead”. I am in chronic and substantial pain and fusion surgery is in near future according to my “crystal ball”.

3. If spondylolysis had occurred as a child, how likely would it have been that some spondylolisthesis and disk degeneration and symptoms would have appeared by the age of 44 (2004)? I know that sometimes there are no symptoms for the whole life. In my case, I have (until now) always been active with running, weight-lifting, backpacking, and the like.

4. Lastly, wondering how much time it takes for the degenerative cascade to take its course. You know, from the time of an adult traumatic spondylolysis to the disk degeneration. Are we typically talking weeks, months, years, decades? Is it a typical scenario that it could take months for the degenerative process to progress into symptoms that drive a person in for diagnostics and treatment?

5. If a fresh spondylolysis was detected as an adult, and disk health is good, it sounds like repair of the pars is advised and may prevent the degenerative process. Is that correct?

Thanks in advance for your taking the time to answer.

[Donald Corenman, MD, DC]

#7647

Question one-“Can a motor vehicle accident cause pars fractures?” Answer-yes but only very rarely and under dire circumstances-ejection from vehicle (no seat belts) or severe impact with body encroachment. The disc will not show signs of degeneration for at least three months and more likely six months or more. The typical mechanism is an extension moment (severe bend backwards).

Question two-“How immediate would be the onset of symptoms?” Answer-immediate. This would be an acute fracture with the subsequent inability to stand upright without significant pain and muscle spasm. No matter what medications you were on, you would notice the pain and dysfunction.

Question three-“How likely is it that the degenerative process could occur and be asymptomatic (painless)? Answer-This is the most common scenario. Most individuals develop this stress fracture when young and don’t develop symptoms until a relatively minor injury causes a tear of the fibrous pannus. You symptoms that have developed after a motor vehicle accident are typical. This does not mean that this preexisting condition precludes you from causation.

Forth question-“How long does it take from pars fracture to degenerative disc disease?” Answer-many years. I am currently researching this and anecdotally, it appears to take at least 10-15 years with some exceptions.

Last question-“If bilateral pars fractures are noted without a slip and with a normal disc, is it recommended to repair the pars fractures?” The answer is still under investigation. If the gap between fragments is large, I don’t think a repair can be effective. Also, the older the patient, the less natural healing response is possible, even with BMP. I can also argue the opposite side. I have repaired multiple adults under this condition successfully. Only time will tell if repair will be effective to prevent degenerative disc changes and what the fracture separation distance is for a successful repair. I have turned down patients for repair with a 5mm fracture separation (they need a fusion) and successfully repaired 3mm separations.

Will repair prevent the degenerative process? Logic and reasoning says it will but only the test of time will answer this question.

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.

[Reasonable2012]

#7653

Hi Dr. Corenman. Appreciate your thoughtful response.

The crash was quite violent in terms of acceleration/deceleration forces. My moving vehicle was brought from 25-30mph to 0mph in about six inches. The forces from this resolved to a powerful jerk backwards on my lower body through the seat belt and a powerful jerk forward to the upper body by virtue of its momentum. Simultaneously, the vehicle was pushed sideways about ten feet and so there were similar force vectors with the upper body tugged to the right by its momentum and the lower body tugged to the left by the seat belt.

It seems to me that a cartilagenous or weak boney structure such as the pars could be damaged by such forces. But maybe that is not the necessary level of forces. My 2004 MRI of the lower back does have a couple of hints that spondylolysis *to a mild degree* may have been present at that time. There was “posterior wedging” of the L5 vertebrae. The neural foramina “keyhole” structure as seen in T2 Sagital off-midline image, was at an angle of 109 degrees relative to the horizontal lower edge of the vertebrae (when it should have been closer to 90 degrees, like the vertebrae above it).

So, as you suggest, possibly there was some congenital predisposition to the spondylolysis and possibly it had already occurred as of 2004 to a limited degree. I did not have acute pain in the lower back. There was mild stenosis at that time and the L5-S1 disk was well hydrated.

The 2012 MRI, taken after the crash, documents the same degree of posterior wedging but the “keyhole” angle is now (on the worst side, there is a little asymmetry between the two) at 129 degrees. There now is about 17% spondylolisthesis (zero in 2004). The stenosis is moderate/severe and the disk is entirely degenerated in appearance. This is about 1.5 years after the crash.

So, to me, it seems reasonable to conclude that the spondylolysis was exacerbated by the forces, and that this pannus tear occurred as a result of the crash. This likely led to the 17% spondylolisthesis, the stenosis, and the disk degeneration.

1. Let me ask you this? How likely is it that an existing spondylolysis could be exacerbated without the acute pain of a fresh fracture? Same question for the torn pannus…could it be torn without acute pain (or pain that could be masked with meds)?

2. Can you clarify your response about rate of disk degeneration? In your first paragraph you indicate 3-6 months or more as the time it takes a disk to show degeneration after a car crash. In Paragraph 4 you indicate 10-15 years or more to go from pars fracture to degeneration.

It would seem to me that in your example of a car crash ejection and a fresh pars fracture, that you could see disk degeneration in 3-6 months. Are you merely saying that the typical scenario is for the pars fracture to occur in childhood and the subsequent pannus tear, spondylolisthesis, stenosis, and disk degeneration to occur many years later? (By the way, is there a name for this whole process of degeneration: pars fracture => pannus tear => spondylolisthesis => stenosis => disk degeneration => miserable life?)

3. It does sound like what you are saying is that what I experienced is common, but with the pannus tear kicking off the whole degenerative process rather than the spondylolysis (which was preexisting but to a lesser degree). My very first, and mild symptoms, started after about 8 weeks. They were starting to get problematic at about 4 months later. By 11 months later they were substantially life changing, affecting day-to-day activities. Would you agree that this is an accurate understanding of the process and a common scenario?

4. Not a question, just an observation. There is no social awareness of this whole lower back degenerative issue and how a car crash or sports injury can interact with it. We commonly know to watch for whiplash injuries, but not this. This seems to be the whole KEY for avoiding the bulk of back injuries in life. From a mechanical analysis, this is the weak point in the design isn’t it? It seems this needs to be taught in schools so people truly understand the motions and forces to avoid. Lower back injuries are crippling and miserable, and they seem to me largely AVOIDABLE once one truly understands the back’s “achille’s heel”.

I am left wondering, if a CT scan had been done at the time of the crash, if maybe the substantial 129 degree spondylolysis would have been detected, and the disk was still well-hydrated. Maybe it could have been repaired at that time, and maybe I could have kept my quality of life. One of those nagging what-ifs…

[Donald Corenman, MD, DC]

#7657

I understand that the forces were great in your accident deceleration but still not great enough or angular enough (your body was captured by the seat and restraint mechanisms) to fracture a normal pars.

Acute lower back pain should normally be apparent within 1-3 days after the accident but with the “shock” of the situation and medications or change in habits immediately after the accident, I could see ignoring this new pain as one of the “general aches and pains” that occur after any accident.

You are asking two different questions to note timing in changes within the disc in MRI after accident. The three to six months time is the time from a new annular tear to the noting of degenerative changes of a disc on an MRI. The 10-15 years is the time it takes normally to see significant changes in disc degeneration from the initial pars fracture. The name of the cascade from pars fracture to degenerative changes of that level is the “degenerative cascade”.

The tear of the pannus is the “straw that broke the camel’s back”. You had preexisting degenerative changes but these were all asymptomatic. It took the tear in the pannus to trigger all the symptoms that have subsequently occurred.

There is not a beginning of enough education and training in regular schools (let alone medical schools) to allow people to understand the mechanics of the lumbar spine.

It is unlikely that at the time of the accident that your pars could have been repaired to prevent progressive degenerative changes from taking place.

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.

[Reasonable2012]

#7673

Thanks again for the followup and clarification! Appreciate your efforts to go above and beyond and make time for people in this way. Also appreciate your apparent expertise in this specialized area.

Regards,

Richard

[Reasonable2012]

#7736

Hey, by the way, ran into someone at a Starbuck’s. She was a professional athlete back in the day, and has clearly been around the block a few times regarding back pain. Like me, she was in a vehicle crash that caused injury to her neck and lower back. She has tried meds, chiro, acupuncture, and evidently is in regular contact with some sort of support group or network of people that all have back issues. Punch line is she recommended me to the Steadman Clinic in Vail. She seems like a credible recommendation to me.

Know it is off topic, but will call your office and talk about if you folks finanacially work with CICP (such as courtesy discount) and would be willing to do the procedure at Poudre Valley Hospital (they recognize the CICP program and are an excellent facility). Am also wrestling with Wyom Work Comp to get them to include it in my claim, but it took months after the crash for me to figure out was injured and something new and its extend, and so it is an uphill battle.

Getting to my main question for you. Have learned a bunch since the last posts. Have a followup MRI this week to see if the condition has visibly progressed in terms of degrees neural foramina has spread acutely (should be at nearly 90 degree angle relative to horizontal edges of the associated vertebrae but mine was at 129 degrees in September, what is it now?). Also want to see if spondylolisthesis and stenosis have progressed. Disc is already completely black/dead.
Have some worrisome symptoms now in neck, arms, and legs from the two injury sites. Much pain too.

In researching the whole lumbar fusion issue it opens up a can of worms. There are a bunch of ways to do it, lots of studies, yada yada. Posterior single-level fusion is clearly the safest/cheapest/easiest. But it does nothing to repair the tear in the fibrous pannus that is the root structural failure, right????
The ALIF is far more dangerous/expensive/harder but it is best at repairing the distance between vertebrae, right?? It also can at least to some degree, reduce the spondylolisthesis and prevent it from progressing in the future!!!! That is HUGE. Can the posterior procedure repair the spondylolisthesis????

I cannot determine if ALIF is able to repair the fibrous pannus…can it?????? That is the million dollar question to me.

And of course I have seen the hybrid procedures that do BOTH. They instrument posteriorly AND they do the ALIF. That seems to give the best structural support. Would you agree? I saw a study out of Hong Kong that showed exceptional results, with many seeing excellent results after an extended period, able to even return to hard manual labor. Is it reasonable to have fairly high hopes of excellent results for such a procedure (of course take all of your communications through this forum based on the info as presented herein, and for educational purposes only, per your disclaimer).

Do you folks do this procedure?

If so:
*Can you specify the hardware manufacturers? and models used?
(Not all hardware is created equal.)
*Is muscle removed in either the posterior or anterior procedure in
such a case? I had muscle removed for the posterior cervical
laminectomy and it of course created an asymmetry in strength and
motion. That would be quite problematic in lumbar region.
*I know there obviously is a loss of motion and the subsequent
additional wear/tear on above and below. But overall there should
be much more structural support and stability after the procedure.
Correct?
*In what other areas, if any, would there be a loss of natural
integrity and strength after the procedure (there are always
trade-offs).
*Is there an approach you would recommend that is even better in
terms of ability to repair spondylolysis and spondylolisthesis and
create (if successful) trouble-free stability and structural
support of that unstable region, with greater long-term success
and likelihood of being able to regain much quality of life?

Cheers,

Richard Warner

Reasonable2012 post=3396 wrote: Thanks again for the followup and clarification! Appreciate your efforts to go above and beyond and make time for people in this way. Also appreciate your apparent expertise in this specialized area.

Regards,

Richard

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