Scar Tissue

Tagged: Scar tissue in the lower back causing nerve root adhesions

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Micronick
Participant

September 6, 2016 at 6:20 am

Post count: 11

#22908

Hello Dr Corenman

I had an L4/5 microdiscectomy in January after servere right leg pain (no back pain) with good result after surgery. However, two weeks later I had a large electric shock pain down my right leg after an awkward movement. Following that when walking a pushing it my leg would often become numb but resided after rest. After 3 months my Dr requested a new MRI with the following findings:

Findings:
In the lumbar spine, there are mild lower lumbar degenerative changes.
At L5/S1 there is mild disc dehydration, but no disc protrusion or neural compression.
At L4/L5 there has been a previous right L4 laminotomy and discectomy.
Mild lateral recess scarring, but no recurrent disc protrusion or neural compression.
The other lumbar discs are normal. Spacious lumbar spinal canal, and normal cauda equina.
Mild multilevel facet joint hypertrophy, but no pars defect, and no foraminal root compression.
Unremarkable bone marrow signal, and normal lower lumbar prevertebral and paravertebral
soft tissues.
In the thoracocervical spine, there is mild lower cervical disc dehydration and bulging, but no
disc protrusion. Normal thoracic intervertebral discs.
The central spinal canal is spacious, and the cervical and thoracic cord and conus are normal.
No myelopathy or cord compression. No foraminal root compression. Unremarkable bone
marrow signal on the available sequence (non-significant mid-thoracic vertebral body
haemangioma).
The upper three midline sacral segments are normal.
Comment:
Chronic mild lower lumbar disc and facet joint degenerative changes, with right-sided L4/L5
post-operative scarring.
However, no disc protrusion, neural compression or cord, conus or cauda equina compression
at any level.
No spinal cause for new lower limb symptoms or urinary symptoms is seen.

I am now 7 months post op and my symptoms are getting worse. My Dr feels there is nothing to be causing the symptoms. I have developed bad back pain at both extension and flexion.

Is it scar tissue causing the issues?

Kind regards

Nick

Micronick
Participant

September 8, 2016 at 2:19 am

Post count: 11

#22926

To add my symptoms are numbness and pain on the outside of my right calf through into the top of foot and middle toes. This is brought on by movement and reduces at rest

Donald Corenman, MD, DC
Moderator

September 8, 2016 at 6:32 am

Post count: 8660

#22928

You need to differentiate between the lower back pain (LBP) and the leg pain by percentages. That is, do you have 70% LBP and 30% leg pain, 80/20, 50/50 or????

It does look like you have scarring of the root. The root is designed to move in the spinal canal like a cable over a pulley. Certain positions (bending and flexing) will stretch the root. If this root is bound down by scar and is fixed to the canal, the stretch will pull on this root and cause it to fire (produce symptoms).

If this is the case, sometimes an epidural steroid injection can give short and even long term relief. If these symptoms continue in spite of physical therapy (gentile stretching of this root), then occasionally a neurolysis (surgically freeing the root from the scar) can be effective but it is difficult to prevent recurrence of scar formation. I have been in rare cases where the root has so much scar that is was impossible to free the nerve without possible further injury and the surgery had to be abandoned. Great care has to be practiced with these cases.

Now, if this level is causing lower back pain and for some reason needs a fusion, then the root can be freed as a fusion allows “disassembly” of this level and much surgical “room” to free the nerve root at the time of fusion.

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.

Micronick
Participant

September 9, 2016 at 6:04 am

Post count: 11

#22933

Thank you for your reply

I would say 60% leg pain and 40% back pain. It seems strange that only 10-14 days after surgery I started to have these problems if caused by scar tissue. I will have another MRI scan in a month or so to see how it looks.

I had a nerve block injection around 8 weeks ago that seemed to make the symptoms worse. My surgeon commented that when he removed the disc fragment that it had calcified – Would this make any difference at all to the outcome?

Both my L4/5 and L5/S1 discs have lost considerable height and possibly may require fusion at some stage.

Donald Corenman, MD, DC
Moderator

September 11, 2016 at 8:57 am

Post count: 8660

#22944

The pain could be from scar, nerve entrapment (foraminal collapse) or recurrent herniation. Make sure you have gadolinium with the MRI to help delineate what is scar and what is bone or herniation.

The nerve block increase in pain could be from a multitude of problems. Some injectionists inject the fluid bolus too quickly creating a pressure “wave” which can cause a pressure phenomenon. Some inject into the nerve itself which can be quite painful (the fluid is designed to “bathe” the nerve by surrounding it). Rarely, just the injection can be irritating. The big question is were you told to pay attention to the first three hours after the injection (see pain diary)? This time is the diagnostic window and many injectionists do not have you aware or record the pain in this period.

Disc fragments commonly are associated with discal spurs (bone spurs that project our of the corners of the disc space and are associated with the annular tear that is the reason for the herniation in the first place).

There is a possibility that you have chronic radiculopathy from the original compression but that is a diagnosis of exclusion (rule out everything else first).

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.

Micronick
Participant

November 4, 2016 at 7:25 am

Post count: 11

#23358

Thank you Dr Corenman

Whats odds % would you give on the neurolysis or fusion procedures being succesfull?

Can scar tissue cause such lower back pain? I also seem to be developing pain upon flexion in my other (good) leg.

Any help would be great.
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Donald Corenman, MD, DC

Average rating:

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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