Relationship Between Spine and Spinal Cord when in MRI scanner

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abprops
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March 12, 2014 at 11:20 pm

Post count: 8

#10516

The explanation of how to read an MRI scan was very interesting. I assume however that the relationship between the position of the spinal cord/dura changes between the situation when the patient is on his or her back in the MRI scanner and when the same patient is sitting, standing and walking. I understand that this is one of the benefits of the type of MRI scanner which allows the scan to be bone when the patient is standing.

Can you help explain how the position of the spinal cord and spine or spinal canal changes when sitting, standing and walking as against when in a horizontal position within a vertical MRI scanner?

Donald Corenman, MD, DC
Moderator

March 15, 2014 at 2:05 am

Post count: 8660

#10531

The spinal cord actually “floats” in the spinal canal. The cord is heavier than water (the CSF it floats in) so on a normal MRI, the cord will be more toward the bottom of the canal. When standing, the position of the cord will depend upon the position of the head.

In my opinion, the standing MRI has more problems than benefits. The data on an MRI picture is gathered slowly, much like a picture in the old wild west days. If there is motion while the date is gathered, the image will be blurry. It is much easier to lie still when you are lying down than when you are upright.

Also, the magnet strength is much less on a standing MRI than on a typical “lie down” MRI. The magnet strength is much like a flash on a camera at night. The stronger the flash, the better quality of the picture.

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.

abprops
Member

March 18, 2014 at 1:46 am

Post count: 8

#10556

Thanks Dr Corenman for a very full explanation.

What about a situation where following surgery a pseudomeningocel develops over the back of the spinal canal, filling the dead space resulting from removal of bone and tissue during the laminectomy resulting in compression of both sides of the dura against the spinal cord and over against the anterior surface of the spinal canal?

A conventional MRI scan could show no evidence of spinal cord compression but would that be true when the patient sat up, stood errect or walked about?

Would the change in position of the head, spine, and spinal cord result in compression of the spinal cord due to the natural swaying movements of the patients body and spine?

Donald Corenman, MD, DC
Moderator

March 18, 2014 at 2:23 am

Post count: 8660

#10557

There are two different fluid filled masses that can occur after surgery in the back on the canal. The first is the most common one and always develops after surgery. This is a seroma, a fluid-filled region where the bone and ligament previously compressed the dural sac and is now gone from the decompression.

This area is now an “empty space”. The compressed dura expands to fill some of the space but the rest of the space has to be filled by something and that something initially is fluid. Occasionally, this fluid can be compressive but will resorb over time.

A pseudomeningiocele is a dural leak that heals with a portion of the fluid still outside the dural sac and still connected to the dural contents by the small tear in the dura. These may be symptomatic or not. If symptomatic, these pseudomeningioceles can be repaired by fixing the leak in the dura.

The standing position will generally not affect the size of the fluid pocket although standing does increase the pressure at the bottom of the dural tube.

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.

abprops
Member

March 18, 2014 at 5:03 am

Post count: 8

#10558

Thank you again Dr Corenman for yet another excellent explanation.

The fluid filled mass I referred to is a pseudomeningocel. The defect in the dura did not heal but remained and expanded in size. Hence the pseudomeningocele was symptomatic. The defect being connected into the pseudomeningocele with a permanent connection and one way valve preventing back flow of cerebrospinal fluid.

In this situation the images produced by a conventional MRI scan when the patient was not moving showed no evidence of compression of the spinal cord. Would the spine, spinal canal and the spinal cord not adopt different positions when the patient was standing and walking. Would the change in position resulting from the patient walking, bending etc, not result in compression of the spinal cord. Particularly as the patients walking gait forced cerebrospinal fluid out from the dura into the pseudomeningocele.

Conventional MRI images at 6 monthly intervals over a period of three years showed the pseudomeningocel compressing both sides of the dura against the spinal cord and against the anterior wall of the spinal canal over the combined length of the T9 and T10 vertebra. The larger than expected defect in the dura was located following investigative and corrective surgery done three years after the laminectomy done to remove an intradural schwannoma tumour at T9.

Donald Corenman, MD, DC
Moderator

March 19, 2014 at 2:30 am

Post count: 8660

#10565

If this is a pseudomeningeocele at T9-10, the pressure head when standing is not that great. However, if it has a ball valve effect (“one way valve preventing back flow of cerebrospinal fluid”), then this can cause a pressure phenomenon like a spinal canal stenosis.

Conventional MRI will delineate the defect as the fluid compression and the compression will not change with standing vs. supine position with the ball valve effect. The corrective surgery performed three years after the removal of the schwannoma should have corrected this pseudomeningeocele.

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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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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