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Dr. Corenman, I’m curious on something in this last post that kind of caught my eye. You have to be prepared to be ruled out for surgery…
My diagnosis is a little bit different than this gentleman, however we do have a common problem, a pars fracture. Mine is at the l5-s1 with some left formainal stenosis due to a slight bulge in l5 disk.I’m curious becuase you made light of something that my doctor had brought up in that, if we were to have a sedentary type lifestyle we might, key word might be able to avoid surgery. If we choose to be active we might have no choice but to have surgery.
In my case, I have tried a somewhat sedentary route, meaning, I have not played golf, skiied, bowled, been back to the gym, and I’m sure there are other things. However my job is a mechanic, it’s what I’m trained to do, it’s what I know, and it pays my bills. I have had to lean on my buddy’s at work to do a few of the more heavier or awkward (pretzel) body position jobs, this has allowed me to reduce my pain level down to 2-4 instead of say 4-8.
I have tried and actually still trying to take steps to be in a more sedentary job atmosphere, however, it requires time, politics, additional training, credentials, so it’s not an automatic thing for me. I also can’t lean on my buddy’s forever, it’s not fair to them.
So where I’m going with this is, you mention surgery being ruled out, in your experience, I assume insurance co’s have the oh mighty say all, and what in a case like mine or this gentleman here would rule surgery out or I guess be denied? Because honestly, if myself or this gentleman were a new hire, and didn’t have our coworkers, friends support, we’d have to hit the ground running, and honestly, I’d be at home on fmla with no pay right now due to immense pain, so technically, you could say, I can’t perform my job, I can’t enjoy the activity’s I’d like to do, and truthfully, even if I was not 41 years old more like 65, I want to at least maybe golf in my retirement. Thank you sir for your time and experience for us to learn.
Dr. Corenman post=1670 wrote: You have to remember that these are just suggestions and that you have to gain the support of your treating physician to carry these suggestions through. I have never examined you so there are no specific recommendations that I can make.
You have indicated that your symptoms have improved in the last couple of weeks and that your benefits will run out soon. You are thinking of returning to your occupation. The question then is- can you go back to being a firefighter with the all of the required lifting and spinal loading? The only way to test the possibility of return is to recreate the typical loads on the spine that will be seen as a firefighter. This can be accomplished by a good therapist simulating the expected load on the spine in a controlled environment.
This testing can however cause a substantial flair-up so you have to be prepared for an exacerbation of your back pain and again, this has to be ordered by your physician. I am only giving you suggestions.
If you cannot load your spine without pain, you have a choice. You can live with the restrictions and get a sedentary job. You have seen that with restrictions, the spine pain becomes manageable. You may not be able to participate in the sports you want to but you may be able to avoid surgery.
If you want to see if surgery can reduce your spinal instability, you would need to undergo a work-up to determine the pain generator. You have already had numerous injections which were non-diagnostic. The next test could be a discogram. You have a relatively normal looking L5-S1 disc. The L3-4 disc is degenerative with the pars fractures and the L4-5 disc is mildly degenerative.
The discogram may indicate that you are a surgical candidate but you have to be prepared to also be ruled out for surgery too.
Dr. Corenman
If the injury is not related to a workman’s compensation claim, generally the insurance company relies on the judgement of the surgeon to recommend surgery. This may be changing somewhat as I am seeing more denials than before from certain companies who use criteria that are non-surgical biased.
Regarding being ruled out for surgery, I use certain criteria to determine if the patient has a disorder that will benefit from surgery. If the problem is lower back pain as the majority of complaint, then in many cases, the discogram test comes into play. This test will indicate if the disc is the pain generator but also much more.
The test is blinded. That is, the patient should have no idea what level is being tested (normally two or more levels are tested). This takes some of the volitional component out of the test. There are also some patients that are “pain intolerant”. Not like the normal population but very highly sensitive to any type of pain. The discogram will identify this subset of patients. Post-operative pain of some type is a reality and these patients may not tolerate post-operative care as well.
There are also patients that have pain processing issues. The thalamus is the organelle at the base of the brain that is the “pain switchbox”. Sometimes, the thalamus can malfunction and identify pain where there is no disorder. The discogram identifies these patients by positive tests at normal anatomic levels. Surgery would generally not benefit these individuals.
The final point I want to make is that generally, these disorders are painful but not dangerous. Some patients can reduce their lifestyle physical demands and be satisfied with the reduced pain that accompanies reduced demand. Other have occupations or advocations that require spinal loads which make tolerating the pain impossible.
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.First of all Happy Easter, and thank you for all your insight with this issue . As I’m sitting here in bed because I could not make it to Easter Mass because of the pain I’m in. I think I’d have this pain no matter what profession I’m in. It’s constant and every day activities seem to maker it worse. I would hope that I wouldnt be ruled out regardless of my profession if i get to that point. My next appointment to the pain doc is April 24th. I am going to suggest the discogram. I think my pain is not coming from the Pars since the injection into the pannus did absolutely nothing . And my pain is about two levels down and almost past my belt line. What are the odds that the pars is a symptomatic and just a coincidence. The MRI says there are central buldges on the L5 level and the emg says there is a pinch on that level . I feel that the calf pain and all other symtoms ( pins and needles) must be related. Could it be we are chasing an injury and pain thatcjust isnt there. Just say if it is a bulge pressing on my spinal cord could that cause the bilateral pain and others symptoms. Also if it is a bulge what options do I have then?
Happy Easter!
If you think you would have the pain no matter what profession you are in, you probably should consider surgery. The pannus injection again can be a false negative injection- pain actually caused by the pars fracture but no relief with an injection. More likely than not, the segment with the fracture is causing your pain but proof is needed before surgical action is undertaken.
The L5-S1 section looks to be normal on MRI so don’t focus on that level for your pain generator. The L4-5 segment does have some degeneration so that could also be painful but less likely than L3-4. Do not focus on the EMG as without compression of a nerve, the test does not help for surgical indications. Calf pain could be from irritation of the L4 nerves at the pars fracture level but that is unlikely.
There are patients that have chronic radiculopathy (see website) but for no reason than inflammation or prior stretch of the nerve. This cannot be revealed by any imaging study so great care has to be taken to diagnose this issue. Read this section carefully to understand this dilemma.
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.As posted I will discuss the discogram with the pain clinic and also maybe doing another diagnostic injection on l4 l5 level . I have 18 months to return to work as per my contract . I’ve been out since 12/15 so timeliness essential for a correct diagnosis and surgury if needed. I just hate the waiting between office visits! I have a MRI from 2008 that I sent you in which the pars was not noted. Should I mention that to the Drs or is that of no value to a diagnoses of my pain? in your opinion will work comp stop my quest for the reason for my pain. I assume they won’t as for they want me back as much as I do?
What was missed or not on your 4 year old MRI should be of no consequence. I cannot comment on your particular workman’s compensation company but generally, most companies want you to improve and will support a surgical work-up.
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. -
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