sacralization of L5

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Donald Corenman, MD, DC
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October 10, 2012 at 6:28 pm

Post count: 8660

#7150

It would be highly unusual to have a shortened psoas muscle that torques the hip joint. Look more toward internal derangement of the hip or nerve root compression causing pain. A good diagnostician is needed.

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.

Sambo
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March 31, 2013 at 5:57 pm

Post count: 7

#8310

Hi Dr, I had ALIF at L4/5 2 years ago with a good result. I am a K9 Police dog handler and returned to full operational duties fairly quickly (3 months). Besides a bit of “bone ache” feeling at L4/5 after running a 3km track with my dog, I can pretty much do what I want. Prior to having ALIF, I always said to my surgeon I felt the origin of my back pain was coming from the left around my sacrum, but clearly on MRI L4/5 was gone, so we addressed that, but the very painfull ache in my lower left is still there. Of note, if I ever had a flare up of my L4/5 disc is was as a result of sleeping on my left side or carrying things on my left. After ALIF, very painfull still lower left side, worse when sitting, actually better when running, I don’t fell it. Aches down into my hip, buttock and quad also. Also painfull if I sleep on that side, some relief sleeping on the other. Been back to my spine surgeon, had a bone scan and it showed no increased uptake. Had an injection in my enlarged transverse process at L5 on the left near the sacral ala and awesome immediate relief. I actually said to the radiograopher when he put the needle in, “yeah thats right on it”. Felt better for a few days, but still now chronically aching. The injection was 18 months ago and I have not been back for another. Saw my spine surgeon last week and he said, he has seen 2 cases where same area has proven to be the area of pain (positive on injection and bone scan) and he has removed the patients small piece of bone through minimally invasive surgery, with a laser I think. He is a fantastic surgeon and I trust him completely. He said for him to be convinced that the enlarged L5 transverse process was causing my the drama, I would need a positive on injection and bone scan. 2 questions, if it is the area causing me the pain, is it possible to not show up on bone scan, as I said great relief with injection, and is it a fairly simple procedure to surgically correct. He said I can be back to Police K9 duties in 6 weeks, but he has to be sure it is the source of pain. Interested on your thoughts re same? Thanks very much.

Donald Corenman, MD, DC
Moderator

March 31, 2013 at 9:17 pm

Post count: 8660

#8311

Continued pain at the same area that you had prior to surgery with very good relief after a transverse-alar block (this is the articulation that occurs with a sacralization of L5 to S1) has three potential sources. One is a lack of fusion at L4-5 (pseudoarthrosis at L4-5), another is compression of another nerve at a level above and the last is this articulation. I would agree with your surgeon in that pain from this transverse-alar articulation is rare (I have seen only two painful cases in my career and I have seen many of these articulations).

First test I would order with a patient in your circumstances is a CT scan. This would confirm a solid fusion of L4-5 (or not). The second test is an MRI. This would be able to determine if there is any other compressive structures (herniations and such) that could cause your symptoms. Also, the MRI could determine if the transverse-alar articulation is moving and causing stress on this joint. The STIR images cut through this region are the ones that would be important. You must make sure that the technician that performs this MRI makes the cuts that go through this area.

Finally, if all the other potential pain generators have been ruled out, the transverse-alar articulation is then injected to block the potential pain fibers (like you had performed previously) with good temporary results (see pain diary on the website). If great results, you would be a candidate for either removal of this articulation or fusion of this segment.

I say possible fusion in that I had removed the painful transverse articulation in both of the patients that successfully completed the workup. One had great relief. One had continued pain most likely due to this segment being non-mobile for their entire life. Removing the articulation abnormally increased mobility of this segment and that was painful for this individual. A subsequent fusion of this abnormal segment relieved the pain and allowed return to an active lifestyle.

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.

Sambo
Member

April 1, 2013 at 8:02 am

Post count: 7

#8318

Thanks Dr. I will go ahead with the CT and MRI passing on the info to the tech about making sure the cuts go through the right area. I did have bulging and wear at L3/4, the level above fusion, and we considered fusing that level as well but we decided to go on the coservative side which I am grateful for at this stage. Maybe it is that level causing me drama? I hope not as I do not want to go through another fusion, it was very stressful for me post op as I was unsure if I was ever going to get back to Policing. Thanks again.

Donald Corenman, MD, DC
Moderator

April 1, 2013 at 7:04 pm

Post count: 8660

#8319

Understand your reluctance for a fusion as the rehab for your type of work can takes as long as six months. Keep us posted regarding your progress.

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.

Sambo
Member

April 2, 2013 at 2:15 pm

Post count: 7

#8328

Dr, Thanks for caring and taking the time to give me, and us, you highly valued thoughts. I truly believe this is where my problem is, and before fusion I always said to physio’s, chiro’s and Dr’s, who I only saw when the disc flared up, that wherever the pain is coming from its on the left and always put my finger on that area. Its actually a much larger piece of bone that the other side to the feel and during certain training I do, especially lying leg raises on my back, that area clicks constantly (I now do not do anything in training to promote that). I have had a series of X RAYS done by the chiro many times over the years and on the side where I do have the L5 enlarged transverse process, the hip is a far bit higher. For years the chiro’s have tried to even them out working on that left hip when adjusting, but still remains high. When I used to have a disc flare up, the L5 transverse process was very painful during adjustment on that side. All chiro’s have said reason my L4/5 wore out was due to the fact I have the L5 transverse process – not sure if this is right or not. But if this is true – I feel like a ticking time bomb as it would then be only a matter of time before another disc goes – and with Police K9 duties I reckon I couldnt do another fusion, it would end my career and the reason I get up each day. Just 3 questions please:
1) If the bone was removed would my hip on that side drop down – we have tried everything to get it to even up with no luck
2) If there is no increased uptake to that area on bone scan, but positive on injection (ie, pain relief) and indications on MRI that there is an issue there – would I be a candidate for surgery? I have already had a bone scan with nothing showing up, but great result from injection temporarily.
3) Could a transverse process, coupled with hip being raised on that side, be a reason for discs wearing out.

I am getting a work up as you suggested and let you know how it goes, if I was a betting man, I am sure this is the area causing me the drama.

Thanks, Dave.
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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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