Re-herniation following recent decompression / revision surgery

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jayd10033
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April 17, 2024 at 9:53 am

Post count: 79

#36210

Hi Doctor –

So following microdisectomy and laminectomy on 2/27, I have re-herniated with symptoms greater than even before my previous procedure. Specifically, my left leg is weak, can’t do a calf raise at all, and now walk with a limp. Add to that the discomfort and pain that comes with sciatica.

New MRI (results below) confirmed re-herniation with left sided compression. I’m slated for a revision surgery next week, possibly with the addition of a Barricaid if I’m a candidate. Doctor said it’s hard to tell from MRI definitively if the size of the tear would qualify.

I wanted to ask you about ADR for L5-S1.I believe I read an article or commentary from you about it, and that you said it is NOT a good idea, especially at that level. Do I have that right? My understanding is that in Europe it is done much more than here for L spince.

Thank you,
Joshua

MRI Results:

EXAM: MRI LUMBAR SPINE WITHOUT AND WITH CONTRAST

HISTORY: Lower back pain. Status post interval L5-S1 decompression.

TECHNIQUE: Multiplanar, multi-sequential MRI of the lumbar spine was obtained on a 3T scanner using a standard protocol.

IV Contrast: 14 ml of Clariscan was injected from a 15 ml single use vial.

COMPARISON: MRI lumbar spine 11/15/2023.

FINDINGS:

For purposes of this dictation, the last well-formed disc space will be labeled L5-S1.

L5-S1: Patient is status post interval bilateral L5-S1 hemilaminectomies and central leftward L5-S1 discectomy.
There is enhancing fibrosis within the postoperative site and left greater than right epidural space.
Interval, postoperative changes in the posterior paraspinal soft tissues at L5-S1.

Small, nonenhancing, approximate 0.5 cm CC by 0.4 cm AP by 0.7 cm transverse dimension, nonenhancing, disc left posterolateral disc extrusion surrounded by postoperative fibrosis (Key images provided). There is impingement upon and posterior displacement of the descending left S1 nerve root sheath.
No central spinal stenosis or significant foraminal narrowing.

OSSEOUS STRUCTURES: Redemonstrated, status post L3-4 discectomy, placement of metallic L3-4 artificial disc and left-sided posterior instrumented metallic spinal fusion L3-4. Stable findings.
No compression fractures. No destructive marrow processes or marrow edema.

ALIGNMENT: Nonspecific straightening redemonstrated.
Redemonstrated, grade 1 retrolisthesis L2-3.

SPINAL CORD AND CONUS MEDULLARIS: Conus medullaris is at T12-L1. No enhancing mass lesions, abnormal signal or abnormal enhancement is seen involving the included distal thoracic spinal cord, conus medullaris or cauda equina nerve root sheaths. No intraspinal masses.

PARASPINAL AND INTRA-ABDOMINAL SOFT TISSUES: Unremarkable.

INCLUDED THORACIC SPINE AND SACRUM: Unremarkable.

DISCS: Redemonstrated, mild L2-3 spondylosis.
Redemonstrated, mild L5-S1 disc space narrowing.

The following axial levels are imaged and detailed below:

L1-L2: No disc bulging or herniation. No spinal canal or foraminal stenosis. Stable.

L2-L3: Redemonstrated, uncovering of the disc by spondylolisthesis. Disc bulging with interval, left posterolateral intradiscal enhancement suggests fibrosis (axial post gadolinium enhanced axial T1-weighted image 10, series 10). Redemonstrated, mild left lateral recess spinal stenosis. No significant foraminal narrowing.

L3-L4: No disc bulging or herniation. No spinal canal or foraminal stenosis. Stable.

L4-L5: No disc bulging or herniation. No spinal canal or foraminal stenosis. Stable.

IMPRESSION:
1.Status post interval bilateral L5-S1 hemilaminectomies and central leftward L5-S1 discectomy.
2. Enhancing postoperative fibrosis within the L5-S1 operative site and left greater than right anterior L5-S1 epidural space with superimposed, 0.5 cm x 0.4 cm x 0.7 cm, left posterolateral nonenhancing disc extrusion surrounded by postoperative fibrosis impinging upon the descending left S1 nerve root sheath.
3. Redemonstrated, status post L3-4 discectomy, placement of L3-4 metallic artificial disc and left-sided posterior instrumented metallic spinal fusion hardware L3-4.
4. Redemonstrated, mild grade 1 retrolisthesis L2-3.
5. Redemonstrated, mild L2-3 spondylosis, disc bulging with interval development of left posterolateral intradiscal L2-3 enhancement/fibrosis and continued, mild left lateral recess spinal stenosis.
6. Otherwise no significant interval change.

jayd10033
Participant

April 17, 2024 at 2:38 pm

Post count: 79

#36211

One other question. I believe the herniation happened at least 2 weeks ago, but the calf weakness only started on this past Sunday 4/14. I am having surgery Tuesday 4/23. Do I have a good chance of regaining full strength in my calf?

jayd10033
Participant

April 24, 2024 at 8:13 pm

Post count: 79

#36215

Update, had the surgery 4/23 and all nerve pain/radiating pain is gone. 8mm Barricaid implanted. Placement looks good as per Fluoroscope image. Calf weakness persists and may take weeks/months to recover with PT, etc. Hoping this is the last spine intervention I’ll need, at least for years and years!
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Donald Corenman, MD, DC

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81 reviews

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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