SI Joint issues post TLIF fusion..

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BIG{HIL
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January 13, 2012 at 7:18 am

Post count: 3

#5363

I had a TLIF Jan 2010 due to DDD, Protrusion and annular tear. I had a lot of lBP, sciatica, hip and buttocks pain. After 6 months of PT and follow ups my surgeon finally sent me back to PM b/c I was in worse pain in my hip, buttocks area. I did have union at the l5-s1 where the fusion was done. PM and the neurosurgeon came to an agreement that all my pain was being generated from my L Si Joint. Prior to the fusion a discogram was done followed by CT and confirmed the tear and IDD at l5-s1 was my pain generator. They did 2 diagnostic SI injections and I had instant relief for about 4 hrs then the same pain returned. They did 1 with cortisone and then a RFA after a lateral branch block. I only got temp relief. I went back to PT and after 16 visits I was in agony. So PM said I had 2 options a take pain meds or see a Ortho Spine specialist. After seeing the Ortho doc he recommends a SI fusion with IFUSE on the left side. So if this is my “pain generator” why would the discogram be positive? This surgery is relatively new and I am concerned the fused spine and the L SI Joint being fused will make the R joint have dysfunction next. Do u know any surgeons who do the IFUSE by SI BONE? Are the results any good? I just want any advice or opinions from someone not local.. I also have started to have severe pain in my neck, shoulders and only occasionally in my forearms. I had a MRI 4 yrs ago and it showed diffused annular bulge that extends into the foramina. The foramina may be narrowed and moderate facet hypertrophy no canal stenosis. This was at c5-c6. My pain and stifness has gotten a lot worse since 2008. It seems to have worsened since my back was fused if this makes sense? I can not sleep from the pain in my back and now my neck burns when I lay down and at times my face will actually twitch which is annoying. Everything is on my left side. Is these symptoms of something that has maybe gotten worse in my neck? Due to my SI Joint and TLIF I have really not payed my neck much attention until the last 6 months or so.. Any insight, suggestions or advise would be greatly appreciated..

Donald Corenman, MD, DC
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January 13, 2012 at 1:06 pm

Post count: 8660

#5367

To summarize, you had hip, buttocks and lower back pain- I assume on the left side. You had a workup with discograms which identified L5-S1 as the level that caused pain. Did you also have some nerve root compression from disc herniation or from foraminal stenosis on the left (see website for description)?

After surgery, I assume a CT scan was performed as the surgeon told you that you have a solid fusion. Unfortunately, the symptoms are even somewhat worse than they were before surgery. Are the symptoms the same as before surgery but worse or different than before but worse? Without a CT scan, how did the surgeon know if there was a solid fusion?

Sacroiliac joint origin of pain is unusual after a TLIF at just the L5-S1 level unless there was a bone graft taken from the sacroiliac joint region. Did you have a graft taken here? Most times, sacroiliac joint pain is referred from L4-5 or L5-S1. To make sure it is the sacroiliac joint as the pain origin, ask if the surgeon will consider a selective nerve root block (SNRB) at L5-S1 on the left. If that gives you no relief, then the sacroiliac joint can be considered the pain generator. However, if that block gives you relief, your pain most likely originates from the L5 nerve in the foramen at L5-S1.

There are occasions that the L5 nerve can be irritated with a TLIF performed on that same side (extremely rare if the TLIF was performed on the opposite side). If the SNRB gives relief, a new MRI or even CT is indicated to look for something called a BMPoma or a bone spur. If the surgeon used BMP- bone morphogenic protein (and many do) and there was some growth of an amorphous mass (BMPoma), then it may be indicated to surgically remove the instrumentation (assuming a solid fusion) and clean out the foramen to decompress the nerve.

Fusion of the SI joint for pain reasons is unusual but you do have a diagnostic block and a failed rhizotomy behind you. There is a procedure called prolotherapy for the SI joint where a substance injected into the joint is designed to cause fibrosis of the joint. I have seen some reasonable results but be careful of this therapy.

If none of the above yield relief, fusion of the SI joint could be considered. I have never fused an SI joint except for trauma so my experience would not help you here.

Do not confuse the neck and arm pain as being related to your lower back.

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.

BIG{HIL
Member

January 13, 2012 at 10:38 pm

Post count: 3

#5373

Thanks for responding. Yes all my pain was on the L side. After my fusion I did and have had a total of 2 cts and 2 flex xrays and they showed 85-90% union. Prior to sugery I did have a 5mm herniation or they called it a protrusion left paracentral. My annular tear was severe enough the radicular pain was from the chemicals in the annulus leaking they say. I am being told the DI Joint was more of an issue than they originally thought. My pain now is worse than before the fusion in the low left back, hip and groin. It was there before the fusion. The mid LBP and sciatica the fusion has resolved that somewhat.. I did have BMP inserted in the cage and no bone graft. The PM has done a Lateral branch block however.

Donald Corenman, MD, DC
Moderator

January 13, 2012 at 11:27 pm

Post count: 8660

#5374

I am unclear as to the meaning of 85-90% union. Does this mean complete union or “you are almost there” type of union? This can make a big difference. Use of BMP with increased pain in my practice means a new MRI is warranted to look for the “BMPoma”.

You have not had a SNRB of the L5 root on the left yet. In my practice, that would be the next step along with an MRI. If the patient would get great relief, I would focus more on the L5 root than the SI joint. Again- if good relief (depending upon the MRI findings), I would consider removing the instrumentation and exploring the nerve root before considering fusion of the SI joint.

If the SNRB gave no relief or the MRI demonstrated no compression or adhesions of the L5 root, then I would consider a fusion of the SI joint.

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.

BIG{HIL
Member

January 14, 2012 at 11:29 am

Post count: 3

#5378

I say 85-90% in that it was at that at my last CT, so close to being there. I will be sure to address the isssues u have brought up. I am grateful to have gotten great advice. I am not sure what u meant by “BMPoma”? I will post if I have any updates.. Thanks!!

Donald Corenman, MD, DC
Moderator

January 15, 2012 at 9:57 pm

Post count: 8660

#5380

BMP or bone morphogenic protein is a synthetic human protein that causes your own stem cells to turn into bone cells. There are rare occasions that the BMP can “leak” out of the site is was intended for and seep into other areas. At a lower concentration, this BMP seems to cause fibrous tissue, cartilage and amorphous “granulation tissue” to form. This can irritate or compress the nerve root.

If the approach for the TLIF was on the left side, an MRI at least 6 months after surgery can “spot” this “BMPoma”. Surgery to decompress the nerve seems to give nerve root relief in about 50% of the cases. If the CT notes solid fusion, then the instrumentation can be taken out at the same time.

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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