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  • Donald Corenman, MD, DC
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    Post count: 8656

    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
    Member
    Post count: 7

    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
    Post count: 8656

    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
    Post count: 7

    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
    Post count: 8656

    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
    Post count: 7

    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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