RE:MIS TLIF on L4/5 with dura tear, scared of arachnoiditis?

Tagged: Nerve injury after MIS L4-5 fusion surgery

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glo
Participant

May 21, 2018 at 3:31 pm

Post count: 9
#28319
Hello Dr. Corenman,
I would like to give an update to my nerve root injury. It’s over 6 months since my MIS TLIF on L4/5 and I had an EMG/NCS test last week. Here is the report from the neurologist at UCSF:
: The results of nerve conduction studies are abnormal for :
1) reduced amplitude of the left superficial peroneal sensory nerve potential (SNAP) compared to study from 9/2017. The results of EMG studies are abnormal for : 1) fibrillation potentials in the left tibialis anterior (TA) and tensor fascia lata (TFL),
2) an increased incidence of long duration motor unit action potentials (MUAPS) in the left TA, TFL, vastus lateralis (VL), tibialis posteroir(TP) and peroneus longus(PL),
3) an increase incidence of polyphasic MUAPs in the left TA, and
4) reduce recruitment of MUAPs in the left TA, TFL and TP.
These abnormal electrodiagnostic studies provide evidence for:
1)a sub-acute left L5 radiculopathy, and
2)a chronic left L4 radiculopathy.
the decrease in the left superficial peroneal SNAP amplitude compared to prior study would suggest the lesion includes the dorsal root ganglion or possible the lumbosacral plexus. Clinicial correlation is advised.
Compared to the study from 9/2017, the left L4 and L5 changes are NEW. The relative sparing of the peroneus longus and tibialis posterior is unusual. Would consider an MR neurogram of the lumbosacral roots and plexus to confirm anatomic location.

I would greatly appreciate your help in understanding the extent of the nerve root damage…
How bad are the damages?? Are DRG orlumbosacral plexus part of the spinal cord?
Are they reversible? correctable? if not, I was told radiculopathy can spread from extremities to the trunk!
Any advises and recommendation would be greatly appreciated.

thanks,
Gabriela
Donald Corenman, MD, DC
Moderator

May 22, 2018 at 12:32 am

Post count: 8660

#28322

Radiculopathy will not spread to the trunk.

The findings are consistent with both L4 and L5 root injury. This is not improving according to the findings so it may be more permanent problems that you have.

The DRG is the dorsal root ganglion and houses the cell bodies of the sensory portion of the nerves. The plexus is the nerve after it has exited the spinal canal and starts to “mingle” with other nerves (the sciatic nerve is made of L4-S1).

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.

glo
Participant

May 22, 2018 at 9:02 am

Post count: 9

#28324

Hello Dr. Corenman,
Thanks for your quick reply.
I have a few questions and hope you can provide your recommendations:
-Would the nerves damage possibly caused by the dural tear at Left L4 during surgery?
-Would nerve monitoring during surgery prevented damaging the nerves? I know they used Stealth GPS & O-arm but unsure about nerve monitoring.
-You said the nerves damage would be permanent, are there any treatments for damaged nerves?
-Would an MR neurogram as suggested by the neurologist show the location of the damage? If so, would revision surgery resolve the damage and pain/numbness/weakness?
-Would acupuncture or other non-invasive modalities help?
-Would my pain develop into CRPS II as the surgeon is sending me to get evaluation for SCS?

I am looking to consult with other neurosurgeon/orth.spine surgeons for treatment plans. Any surgeons in California whom you would recommend? Any help and advices would be greatly appreciated.

Best regards
Gabriela

Donald Corenman, MD, DC
Moderator

May 23, 2018 at 9:06 pm

Post count: 8660

#28335

Dural tears by themselves do not cause nerve root injury but the tear exposes the nerve roots which are highly sensitive and quite liable to injury. If the nerves are injured when the dura is repaired, this can be a permanent injury.

Nerve monitoring can help to identify injury but many surgeons don’t use this technology.

There is no damage to nerves that can be repaired at the spinal canal level. This is not true if the injury is outside the spinal canal (but yours is within the canal).

An MRI neurogram is good for plexus nerves (outside the canal) but is not needed for your type of injury.

Yes, it is possible that you could develop CRPS but if you have not at this point, it is less likely to occur.

Acupuncture seems to help with symptoms but won’t improve your chances of muscle recovery or paresthesias.

Cannot comment on who to see in California.

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.

glo
Participant

May 23, 2018 at 9:58 pm

Post count: 9

#28338

Hello Dr. Corenman,

Thanks for your reply to all my questions. I am in despair to find out my nerve roots damage is PERMANENT!
a few more questions:
– Would the neurogram show any nerve injury at the dural tear location closed to left L4?
– So you are saying my nerve roots at L4 and L5 were damaged within the spinal canal and fixing the lesion at lumbosacral plexus and DRG will not heal the damage on the nerve roots?
– DO I have spinal cord injury at the L4/L5 level?
– so MRI neurogram will not help me to locate where the nerve root injury?
– Are there other tests you would recommend to help with my situation?
– if acupuncture helps with symptoms only, what should I do to improve my muscle recovery and paresthesias?
– So I am hopeless to even try to find other surgeons to help me repair my injury?
– Would you be able to help me if I schedule a consultation with you?

Please help!

thanks for your time and any helps and advises would be greatly appreciated.

Best,
Gabriela

Donald Corenman, MD, DC
Moderator

May 24, 2018 at 11:31 am

Post count: 8660

#28339

The neurogram MRI will not be helpful to the intracanal injury which is where the injury occurred. The DRG is strictly a sensory nerve structure. You probably have a mixed (motor and sensory) injury. The motor is post-ganglionic and the sensory is pre-ganglionic but that really does not help here.

You have a nerve root injury, not a spinal cord injury. Time will tell if you recover. There is no treatment available for nerve injury. There are tendon transfers for certain patients that have some muscle sparing. I am sorry I unfortunately cannot help in your case.

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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