Right sided pars fracture of L5

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Donald Corenman
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April 25, 2011 at 3:31 am

Post count: 52

#4513

I am an 18 year old tennis player. I saw your video on youtube but it wasn’t much comment room. I am contacting you to hear what you think. I was diagnosed with a right sided pars fracture of L5. The CT scan showed that it was healing. My doctor said that I don’t need the brace because I wasn’t in much pain when I saw him which was 2 weeks after I stopped playing, and he said my left side is holding everything in place for the other side to heal. Do you think that my left side could break from daily living? I haven’t done physical activity(running, weight lifting, tennis). All I have been doing is physical therapy and resting. Do you think that if the CT scan showed that the fracture was healing it will heal all the way, bone to bone? I am not in any pain right now, although I do feel at the site of the fracture some bump it doesn’t feel tender though. So do you think this will heal and I will be fine, or do you think I need to get the brace? It is going to be 12 weeks on friday that I haven’t played tennis. My doctor wants me to get a bone scan to see if it is healing still or not, but the bone scan won’t show if its healed or not, it will just show if there is bone activity still going on in that area? And I don’t want to expose myself to anymore radiation. What do you suggest I do?

Donald Corenman, MD, DC
Moderator

April 25, 2011 at 3:34 am

Post count: 8660

#4514

A unilateral pars fracture of L5 is very common in tennis players and professional skiers. The serve and overhead both cause significant extension (bending backwards) of the spine and this can overload the bone causing this stress fracture. Make sure this fracture is not a facet fracture (a lower fracture in the same bone) as the facet fracture has a different prognosis.

If this is truly a unilateral pars fracture, there is a good chance it will heal but healing will take at least three months. This means no tennis or any exercise that would put your back into extension. Think of this fracture as an ankle fracture. I don’t think you would run, play tennis or lift weights with an ankle fracture- so treat it as that.

Bracing is optional but I like to use braces for this fracture as it reminds you not to bend backwards which destroys the healing potential. This fracture may not heal in spite of your carefully reduced activity. Without healing, the other side that is intact will react to the increased stress. It may go one of two ways. It may develop more bone to compensate for the increased stress (hypertrophy) which is a good development or it may eventually fracture from the overloaded stress.

If the other side does hypertrophy, the pain most likely be reduced but may not completely go away under load. Healing potential can be ascertained with a bone scan but the MRI can also give similar information without a radioactive tracer being used. I always obtain a new limited CT scan (just the fracture area and not the entire lumbar spine) in athletes to look for healing. The fracture is repairable surgically if necessary.

Hope this helps.

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.

gary.notkin
Member

April 25, 2011 at 6:23 am

Post count: 3

#4515

Thank You for replying. This is for sure a pars fracture. So you are saying that if the CT scan showed healing on March 1st that means it will heal all the way? Or it could stop healing half way even if there was healing bone on the CT scan. Do you think I should get the brace now? It will be three months this friday coming up. You think it will still hurt when I start to play? I am hoping to play college and pro tennis and I can’t live without tennis. I don’t want to do surgery, because I know that this is treated conservatively with good results. So what do you suggest I do? I know there are athletes on the pro tennis tour playing with this and they are fine. I am ok with having a little soreness here and there when I start to play again but I don’t want to have the kind of pain that I had when it first happened back in January. I am also using a bone stimulator right now, do you think that might help too? And you are sure that MRI will show if it is healing, because I don’t want to expose myself to more radiation, I did get a localized CT scan of that area at first, but I don’t want to do it again. By the way where is there more radiation Bone scan or localized CT scan, if you could let me know about that too I would appreciate it. Thanks

Donald Corenman, MD, DC
Moderator

April 26, 2011 at 4:01 am

Post count: 8660

#4517

I always worry about a report that notes the “CT scan demonstrates partial healing” as partial healing could mean anything. Ask your doctor if he could replace the bone scan with another limited CT scan of just the vertebra in question. Three months is the quickest time a pars fracture could heal and it can take up to six months. If the CT notes a healed fracture, you would not need the brace. If the CT notes delayed healing- my opinion would be to use the brace. Healing potential can be ascertained by an MRI using the STIR images. If the fracture doesn’t heal with conservative management, you could try to play tennis with the fracture and if it becomes too painful, you could have the fracture surgically repaired.

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.

gary.notkin
Member

April 26, 2011 at 5:23 am

Post count: 3

#4518

Dr. Corenman,

What do you mean the partial healing could mean anything? The CT showed the right pars, but it looked more like a stress reaction, it wasn’t cracked all the way through because there was already bone healing. So it could have stopped? Why is this issue so complicated why can’t it just heal like everything else in the body? The bone scan won’t show if its healed or not, it will only show if there is still healing bone?

Donald Corenman, MD, DC
Moderator

May 1, 2011 at 3:00 am

Post count: 8660

#4524

If the pars is reported to be “partially healed”, that definition depends upon the interpretation of the radiologist. A pars fracture can heal without a full joining of 100% of the bone ends. If the other side of the vertebra is not fractured and the fracture side has 50% of the fracture ends fully united, more likely than not it will withstand extension. Extension occurs with your serve and overhead.

The reason the bone fractured in the first place is the significant forces to the pars generated with these actions. It is a possibility that the fracture can occur again. If the fracture occurs again, you might need a surgical pars repair.

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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