Recurrent disc herniation at L4/L5

Tagged: Motor strength loss and surgical timing

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karob401
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September 30, 2014 at 2:54 am

Post count: 13

#11490

For the past 18 months, I’ve been chasing a lumbar herniation between L4 and L5 discs. Began in March, 2013 with a sports injury disc herniation with broken fragments located on my L5 nerve. Had my first microdisectomy in April, 2013 to remove disc fragments from the nerve and fix the herniation; which relieved the pain for 1.5 weeks until I re-herniated in the same location from fall. I went for the revision surgery in June, 2013, followed by a hand-off to the pain management clinic in August, 2013 to continue with nerve and pain medications for the lumbar and new (post-surgical) hip muscle spasms and radiating pain to my left leg and foot. I was unable to get to the PT as prescribed as my job was relocated and required to drive 3 hrs each way to work. MRI confirmed in August 2014 that I have another significant herniation in the same location that is crushing my L5 nerve.

So, two miscrodiscektomies, three guided endoscope steroid injections (both pre and post-surgical with zero relief), three oral steroid packs, over a year of pain and nerve medications, several localized lumbar corticosteroid shots, twice weekly visits to chiropractor for ultra sound/ cold laser/ massage therapy (with some immediate but, not long lasting relief) have left me with inconsistent recommendations and still, no real progress or pain relief.

I’ve noticed a steadily growing overall decline, including increased lumbar pain and expansion of the now “normal” foot numbness/tingling of entire foot and ankle, as well as new pain that is radiating to both hip joints and somewhere in the lower bottom pelvic region. I decided it was time to go back to my original surgeon and then, to another at Johns Hopkins for a 2nd opinion. Both recommended spinal fusion, however, my previous surgeon said I could go in for a 3rd microdiscektomy (although success rate is slim), if I really wanted to go that route.

I’m scared to death to have a fusion as it is major surgery and one that I can’t readily come back from if it doesn’t work – and the recovery time is so extensive that I’m not sure I can financially afford to recover for the length of time required. I really want to choose the less invasive discektomy with my full commitment, this time to follow all physician prescribed rehabilitation. My question is, it this possible or am I only prolonging the inevitable? I’m no longer employed, I now have the to spend to ensure I do everything per doctors orders and will commit 110% to my recovery.
I am a single parent and need to get back to work as soon as possible. A fusion will take so much longer to recover and has some major risks that I’m afraid to undergo unless it’s my last possible remedy (adjacent disc disease, doesn’t take, etc).

I’m desperate for some advice as to what I should do. I have received lots of differing opinions. Is it possible to recover from a 3rd herniation discectomy or, is fusion really my only option?

Thank you,
KS

Donald Corenman, MD, DC
Moderator

October 13, 2014 at 8:09 am

Post count: 8660

#11516

The reason after a third herniated that disc fusion is recommended has two different reasons. The first is that the nerve root cannot afford to be “banged into” (compressed by a disc hernation) three times. From years of trial and error, we have found that the nerve can only take so much before it permamently malfunctions (chronic radiculopathy-see website). There are even unusual disc herniations that cause permanent damage after just one herniation.

The other reason for fusion is that after the third herniation, the chance of recurrent disc herniation goes up to almost 50%. The chance of recurrent disc herniaton after one is still about 10% but the third seems to have a much greater chance of recurrency rate.

The fusion does require some down time but your nerve is very important and a chronically injured nerve is not something you want.

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.

karob401
Member

October 15, 2014 at 12:57 am

Post count: 13

#11524

Thank you for your response. I’ve been given so much conflicting advice that I certainly have a lot to think about and a difficult decision that needs to be made quickly.
I understand what you’ve said regarding the nerve root damage after a 3rd herniation and the risk for battered nerve root syndrome. This is my only concern that I have going in for a 3rd. I’ve had some nerve damage after the first discektomy so, this is an issue that weighs heavily on my mind. I’ve done a lot of reading and research on this specifically – especially on your website – which is wonderful! Thank you – it has been a great resource for me.

I’m still left wondering if a 3rd discektomy is worth just one more shot – with my 150% commitment of aftercare and rehabilitation, as well as the proper PT both pre & post surgery. I started PT again last week and changed my diet to one that will help with the pain and healing process, as well.

My biggest fear with the fusion is that it won’t work or, if it does, I’ll be headed down a road for more fusions in the near future, due to adjacent disc disease. (my S1 already showing slight bulge due to the L5/L4 weakness). Isn’t this also a high risk and consideration I should weigh against the risk of a 3rd discektomy and possible nerve damage?

When I ask the doctors on my “team” what they would do or recommend for their own wives, mothers, daughters – I get mixed reviews. I’m surprised when some say they would try the 3rd discektomy one more time and if they re-herniated would then, opt for the fusion.

What would you do, if it were you?

Thank you again for your thoughtful advice and great website forum. I’ll continue to keep reading.

Sincerely,
KS

Donald Corenman, MD, DC
Moderator

October 15, 2014 at 10:24 pm

Post count: 8660

#11526

I know that you would like to be able to “control” your destiny by getting a third microdiscectomy and changing your diet and activities to prevent yet another herniation. Unfortunately, the chances of another disc herniation are about 50% regardless of your diet or activity restrictions.

Fusion has a very high chance of working if properly performed. Yes, there is the chance of adjacent segment disease but that chance is small. The chances are much higher of a recurrent disc herniation and/or permanent nerve damage with just another decompression.

If this was my back, I would pick the fusion by a competent and experienced surgeon.

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.

karob401
Member

October 24, 2014 at 5:19 am

Post count: 13

#11580

Thank you! The evidence and expert opinions, yours included, seem to all point to fusion. I’d like to fight it tooth and nail but, looks like I’m losing the battle. So…

I’ve been to my first surgeon who did my initial 1 Micro-D’s – he says that he would (If I insist) perform a 3rd micro-D; although his recommendation is fusion. Subsequent to that I went for 2nd opinions at Johns Hopkins on two separate occasions – both are neurosurgeons. Neither JH surgeons will perform a 3rd Micro-D and have recommended: 1) do nothing and continue as is or, 2) fusion at L4/L5. I saw Dr. Timothy Witham and Dr. Ali Bydon.

How do you determine a surgeons competence? I’ve learned a lot more and able now to ask many more questions than when I had my first mirco-D 1+ years ago but, I don’t know exactly what are the right questions to ask. I’ve researched but, I’m flying blind in this regard. I assume that I’m looking for someone who does fusions regularly. From the two surgeons I metat JH , I like one better (personality-wise) and I’ve found some online videos he’s produced – he seems to not only perform fusions on a regular basis but, is a teaching professor, as well. Dr. Ali Bydon.

Thank you for letting me know what you would do yourself or recommend for a family member. This is very helpful! If you could find some time and provide a bit of guidance on how to select a competent surgeon, I think I might be ready for the fusion. (although I still don’t know if it’s the right way to go for me and remain scared to death about it). :)

Sincerely,
KS

Donald Corenman, MD, DC
Moderator

October 24, 2014 at 10:33 pm

Post count: 8660

#11583

I do think that a fusion is the correct procedure for your situation. Finding a great surgeon is not easy. Chech the section regarding questions to ask your surgeon on this website to understand what some benchmarks are.

If you are going to a university hospital, make sure the surgeon you talk to is going to perform the entire surgery and the fellow will sticktly be an assistant.

I have been thinking long and hard about how to discover who is a good surgeon and this is a difficult question to answer. It might be helpful to ask what the dural leak frequency is. I have about 2 dural leaks in every 500 surgeries generally including revisions so that might be a good benchmark question to ask. Is the dural leak rate 1 in every 100 or one in every 10?

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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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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