Spondylolisthesis Grade I/II spinal fusion revision surgery

Tagged: Pseudoarthrosis, spinal fusion, Spondylolisthesis

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Maria_2017
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February 15, 2017 at 12:41 pm

Post count: 5

#24338

Dear Dr Corenman,

Thank you so much for the possibility of contacting such a skilled spine surgeon.
I have a history of persistent back pain, finding were L5-S1 spondylolisthesis grade I/II with disc degeneration and foraminal stenosis. I had a spinal fusion at this level (4 screws and 2 bars), bilateral laminectomy and a slight reduction of the spondy but not very much. The orthopedist doctor could not insert a cage between the vertebrae ( I think space was too narrow, not sure).

Now 5 years after spinal fusion I still suffer from incapacitating pain, null with lying down (when not inflamed) and pretty severe after starting doing daily life. Saw a couple of neurosurgeons and 2 of them say I might be suffering from pseudoarthrosis, since there is no fusion between the vertebrae. But my surgeon and others argue that the screws are holding it since I my flexion and extension X-rays don’t show movement, unless it is micro movement, they said.

I have central back pain at the surgical site and bilateral leg symptoms that come and go. I am helped by an osteopath to keep this at bay. Also my muscles are weak around this are because I have pain and don’t move as much.

I would be very happy if you could give me some advice to recover my life back. I am only 35 yrs and want to move forward with my life.

Thank you so very much,

Maria

Donald Corenman, MD, DC
Moderator

February 15, 2017 at 1:38 pm

Post count: 8660

#24339

With no cage placed in the disc space, it is unlikely that you have a solid fusion. I would disagree that “the screws are holding it” as these are temporary devices that depend upon the fusion to occur to prevent motion in the long run. You might have a posteolateral fusion (between the transverse processes and the ala of the sacrum) but I would also doubt that. I would think you would benefit from a new CT scan (1mm fine cut) to determine your fusion status and if you do not have a solid fusion, a revision would be appropriate. The CT scan only needs to be performed at the L5-S1 level and not at any other levels to prevent further x-ray exposure.

By the way, you can always get a cage into a disc space in a segment that has not fused. It is essential with an isthmic spondylolisthesis as you need to create space between the vertebra to reconstruct the foraminal height.

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.

Maria_2017
Participant

February 16, 2017 at 6:57 am

Post count: 5

#24340

Dear Dr Corenman,

Thank you so much for your quick reply. I would actually would see you if I was not on in Europe.

When I woke up from my only spinal fusion when they get me to stand up and walk, I had a huge pain in all my left leg that I never had before. From the imaging exams no screw is touching the nerve root, but it is close by. This pain got better over time but sometimes comes back. My question is if I have possible nerve damage?

Also some months ago I did a rhyzotomy on the left leg L5-L4-L3 and L5 transforaminal epidural, did find relief from leg pain but not back pain.

Now I am back to having intense pain with activity and sometimes a shooting pain to my ventral left side (this started a few month ago before rhyzotomy).
Also I forgot to mention that sometimes I have cracking sounds from my spine and some are followed by pain. Is this an indication of vertebral movement and instability?

Is it possible to place a cage even if the space is quite narrow, I believe the doctor tried but could not.

Thank you so very much for your help and care. I am trying to find a solution for this debilitating and depressing situation.

Donald Corenman, MD, DC
Moderator

February 16, 2017 at 2:06 pm

Post count: 8660

#24341

I would assume the new pain in your left leg was from the collapse of the L5 vertebra on the sacrum after the attempted fusion and compression of the left L5 nerve occurred. If you do not place a cage into the disc space to distract the two structures apart, the foramen will narrow further and cause nerve compression.

If you have periods of no to minimal pain in your leg, it is unlikely that you have permanent nerve damage. I assume you have an unstable level that intermittently compresses this nerve root.

It is always probable that a cage can be placed as long as the level is not fused. It takes some time and technique to work the two levels apart but that demonstrates the capability of the surgeon. Find one that has 20 years experience and is meticulous. I have no doubts that a good surgeon in Europe is close by.

Popping and cracking can indicate a non-fused level but can indicate other disorders as well.

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.

Maria_2017
Participant

February 21, 2017 at 2:59 pm

Post count: 5

#24402

Dear Dr Corenman,

Thank you so very much for your answers and for caring for patients who are not yours!
It took me a while to digest your information. And meanwhile I have seen my doctor (orthopedic surgeon) that is very interested in following me but wants to avoid surgery. He told me my vertebra L5-S1 were almost bone on bone so no cage and as you said only posterior fusion (that is if it has taken). I am also seeing a good neurosurgeon and I know he wanted to re-do my fusion and place a cage in between.

My question is if I have some sort of chronic neuropathy? When resting and when I wake up I am fine then when I stand up and start moving is the real problem. Is lumbar burning pain from inflammation or nerves.

I will be having an MRI soon.

My doctor worries that a second surgery might not be of benefit.

Thank you for your dedication.

Maria

Donald Corenman, MD, DC
Moderator

February 21, 2017 at 6:33 pm

Post count: 8660

#24406

Probably, the lack of symptoms from rest are an indication of no significant chronic radiculopathy. The roots become painful when you load the spine and compress the roots. A CT scan (fine cut-1mm slices) will be helpful to understand if there is a fusion and the MRI will note the compression of the L5 roots.

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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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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