Repair of pseudoarthrosis

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Ren24
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January 31, 2015 at 3:08 am

Post count: 21

#12126

Hi doctor
We spoke previously about my neck shoulder and arm pain please note I also am told I have fibromyalgia. I was wondering if you could tell me what to expect if my C5-6 allograft with plating is confirmed to be in fact a failed fusion. I would like to be prepared and do have to get a confirming cat scan yet. I am frightened mostly of what will happen to me if this is NOT a failed fusion and of why I would be having this level of pain. So firstly what is commonly done for this failed fusion and secondly what could possibly be wrong if it isn’t a pseudoarthrosis. Thirdly I have continuing dysphasia with pressure strangling feeling and pain at times in throat at level of fusion. Mod barium swallow dx the narrowing which I’m told it slight I do get tired of having it belittled. It may look slight in film but I assure you it does not feel slight and is very uncomfortable to say the least and causes anxiety attacks which are severe. Is there any chance or ha e u ever heard of exploratory surgery or removal of scar tissue which may be compressing the esophagus? This is something that has decreased my quality of life along with the pain. Any ideas or suggestions would be helpful as well as what I may be I for with it without the repair of failed fusion. Thanks a lot. Ren. Oh I also would like to know if I do have this pseudoarthrosis and need more surgery is posterior more common approach second time or will the front approach be tried again. Since I have the throat issue its a concern to me. Soft tissue mri nothing can be seen at area of fusion due to high artifact and signal intensity for tissue with this type of mri. So nothing was able to be seen there. It was a big blur I was told. I had several stitch accesses approx a month after my surgery that had yellow green pus coming out and ran a low grade 99.2 temp. Very unusuL for me to run a temp for anything. I mean I had an appendectomy at 14 weeks pregnant and had no temp elevation or blood count elevation. Is it a possibility my swallowing and pressure issue could b like am abscess pocketed in there which is being missed due to Inability to visualize this areA. I just know how miserable I am right now and am double firing questions at you I apologize. Thanks for any thoughts you may ha son all that

Donald Corenman, MD, DC
Moderator

February 1, 2015 at 1:06 am

Post count: 8660

#12127

A pseudoarthrosis repair can be performed from the front or the back of the neck. It really depends upon numerous factors. If there is good apposition of bone and no significant spurs projecting out from the uncovertebral joints (see cervical foraminal stenosis), a posterior fusion is a good choice. This is especially true if you had dysphagia (difficulty swallowing) from the previous anterior surgery.

However, if the pseudoarthrosis is atrophic (lots of space with scar tissue/large gaps) or there is significant spur off the back of the spine compressing the nerve root or the spinal cord, a redo anterior fusion is generally a better choice.

Difficulty with swallowing can occur with the anterior surgery as the esophagus is retracted during surgery. The esophagus is really like a snake’s transport system. You can picture how a swallowed mouse causes a bulge in the snake’s long belly. Contraction of the muscles behind the mouse and relaxation of the muscles in front of the mouse propels the body down the “stomach tube”.

Retraction of the esophagus in rare occasions will cause areas of the muscle not to contract. You could then imagine how a food bolus could get “caught” in this area where the muscle does not contract. Dysphagia commonly relents after 3-10 days. Permanent problems can be alleviated in my opinion if the retraction during surgery is “let down” for a period of time to allow the muscular wall to revascularize (regain blood supply).

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.

Ren24
Participant

February 1, 2015 at 3:55 am

Post count: 21

#12132

TThank you for the information. I am now at the 6 month mark after surgery and still having issues. The modified barium swallow actually showed something pushing in from behind the esophagus causing a slight narrowing. Most opinions so far have been scar tissue. Anatomy wise isn’t the windpipe right behind the esophagus at the area of plating and fusionC5-6? I’ve recent started having trouble with shortness of breath wheezing and an increase in snoring/ breathing at night and wake with a horrible cotton mouth and sometimes a sore spot on my tongue from sleeping with my mouth open. Double whammy with sinus issues narrow nasal passages and now maybe issue from the surgery. Albuterol doesn’t seem to help the wheeze. Is it possible that my airway also may have this pressure on it like the esophagus hence causing the exacerbation with breathing and wheezing? I know you are a spine specialist but you have seen people open inside and know way better than I if this is a possibity. Anyway. My whole life weird medical things have happened to me so if it’s a remote possibility I probably have it. Funny but not. So if you have a chance let me know what you think about this as the periodic release of pressure on esophagus during surgery isn’t possible for me anymore. I almost feel although I have all this possible scarring that it may be beneficial to go back through the front just to see what the heck is goin on in there. Sometimes you just don’t know what you will find until you get in there and look in my opinion. Also is it possible to see any of those things if you go in from the posterior aspect? Thanks doctor. Ren

Donald Corenman, MD, DC
Moderator

February 1, 2015 at 10:07 pm

Post count: 8660

#12133

The trachea (windpipe) is in front of the esophagus. The esophagus lies directly on the vertebra. If you have a prominent plate on the front of the spine, this could interfere with swallowing. Normally, the plate does not cause any compression but if there was a large spur off the anterior vertebra and the plate was then placed on top of this spur, the esophagus can be compressed.

You might have obstructive sleep apnea if you note “increase in snoring/ breathing at night and wake with a horrible cotton mouth and sometimes a sore spot on my tongue from sleeping with my mouth open”. You would need to have an ENT consult and possibly a sleep study to determine that.

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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