Stand alone ALIF on a male

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john123
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February 7, 2015 at 2:16 pm

Post count: 30

#12160

Thank you again. It sounds like I should go to the surgeon that has the best results with the way their were trained. I know the surgeon that I just met with can perform the surgery with TLIF, but thinks that TLIF is a step below 360. and I agree with you, if he doesn’t like the results he gets with TLIF than he is probably not the right surgeon for TLIF.

I have consulted with 5 surgeons, – one wants to do PLIF, another stand alone ALIF, another 360 with perc screw, another 360 with posterolateral fusion and one other with TLIF. It would be nice if their was some commonality. As a result, I appreciate you putting all of this in laymans terms. Surgeons do not like to explain themselves or ever be questioned. You accept what they want to do or your out.

So PLIF is like doing two microdisectomies on either side and inserting two cages?

Is it that big of a deal to retract two nerve roots?

The reason why I ask is that there is surgeon locally with high ethics that I do trust that performs PLIF; he claims he can get a good result.

In short, I really do not feel comfortable with anyone going through my abdomen. I understand the process and it sounds like most people do rather well, but I am just not an ALIF guy. As a matter of fact, I think it is a short cut for a surgeon to not have to do as much work and leave you with the risks of cutting through the abdomen in addition to running up a higher bill for BNP, vascular surgeon, and more hardware. Perhaps I am a bit jaded.

I would like to leave my guts, arteries and genitals alone. So I am trying to figure out where to go from here, because I really only have one guy that goes through the back that I comfortable with and he does PLIF and not TLIF. He says he likes the angle better ?

So would it be prudent at this point to to find a surgeon that has expertise going through posterior ? Pars comes out, screws go in, fuse verterbrae and gutters and I’m good to go !

Donald Corenman, MD, DC
Moderator

February 8, 2015 at 11:10 pm

Post count: 8660

#12161

You have found out through experience that if you ask five spine surgeons (or neurosurgeons) their opinion, you will get ten different answers.

As I have noted before, I think the TLIF is the best procedure for an isthmic spondylolisthesis as the surgery addresses the spurs that originate off of the fractured pars, fuses the disc and transverse processes (ala of the sacrum) and addresses both nerve roots (decompression) with retraction of only one root on one side.

PILFs will work but in my opinion, there is no need to retract both roots which is what is involved with a PLIF. An ALIF is not necessary as the abdominal wall does not need to be incised (with a TLIF) and no great vessels or ureters need to be retracted. “Minimally invasive” techniques are really not minimally invasive and fail more often than minimal incision standard techniques (MIMS technique-minimal incision microsurgery).

All that being said, ALIFs can work, PLIFs can work and 360s can work to repair this disorder. It really depends upon the experience and technique of the surgeon you choose.

Your quote is probably the best and simplest description of the surgery I have heard (“Pars comes out, screws go in, fuse vertebrae and gutters and I’m good to go”).

The surgeon who does the PLIF is probably a neurosurgeon as this speciality tends to like the PLIF. If he or she is good and comfortable with this procedure, this is probably the best acceptable alternative.

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.

john123
Member

February 9, 2015 at 2:20 pm

Post count: 30

#12167

Yes, you are right once again. The surgeon that wants to do the PLIF is a neuroseurgeon. Is TLIF more on an ortherpedic specialty ?

After doing so much research your argument for TLIF is the most plausible for me. It would appear that some of the other “minimally invasive” surgeries like ALIF would lead to a revision surgery down the road to remove parts fracture. Also you mentioned previusly that ALIF was more for grad 3-4 spondy. MY spondy has not change at all in 4 years. As a matter of fact the grade one slip has always been there, but I guess no moblie.

Questions:

1.) Why do you insist that the Pars defect be removed when there are so many surgeons that say leave it alone if you do not have leg pain. I understand that bone spurs need to removed, but if it is not causing leg pain then why do you believe it is mandatory to take pars out ? for bone graft purposes ?

2.) Also another concern is the size of the cage being put in to the disc space, you have said previously that the TLIF is a large enough cage to support the spinal column but many “neurosurgeons” emphatically disagree with this. They say the smaller TLIF cage will not give enough support up front, which will lead to weakness and instabilty. (doesn’t cover enough area)

3.) When you put in cage for TLIF how much of the disc space do you remove and do your add BNP or other graft to the surrounding cage to help bone grow together ?

4.) You said above “TLIF is the best procedure for an isthmic spondylolisthesis as the surgery addresses the spurs that originate off of the fractured pars, fuses the disc and transverse processes (ala of the sacrum) and addresses both nerve roots (decompression) with retraction of only one root on one side.”
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What do you mean it decompresses both nerve roots ? You mean when you remove the pars defect it will decompress whatever nerve roots they are pressing on ?

5.) The surgeon who does the PLIF is probably a neurosurgeon as this speciality tends to like the PLIF. If he or she is good and comfortable with this procedure, this is probably the best acceptable alternative.

Do you feel this way because the other neuro wanted to do 360 first even though he does TLIF as well. I believe he can perform surgery. He did posterolateral fusion 5 years ago (never removed disc? for a friend with spondylolithesis from pars fracture and he is doing great. He also did surgery 10 years ago on another friend with DDD spondy, again never put in cage, just screws and rods (posterolateral fusion) and he is also golfing, traveling with little to no pain.

It doesnt sound like any one was using cages 5-10 years ago ?

So I am assuming he can do a TLIF for me with a similar result.

You seem to be have the the best intuition when it comes to this. I really want to stay away from PLIF.

Will PLIF clead out entire disc space and provides as much bone graft as TLIF. Does PLIF also cram some bonegraft in the disc space next to the cages ?

Sorry, I know I a rambling, but I am getting close to scheduling this. I have some decent surgeons around, no one like yourself. but I think that can give a good result. I really only have on shot at this. I would to like ski and skate again. Do you think this is possible ?

Do you know of anyone at the Cleveland clinic or Pittsburg/Buffalo area that specilaized in TLIF ?

john123
Member

February 9, 2015 at 2:28 pm

Post count: 30

#12168

Also, will TLIF or PLIF cause muscle spasm or muscl pain after surgery. My massage therapist saysshe is constantly giving deep tissue massage for Posterior fusions. Any way to avoid this.

I guess with a 360 I would run into same problem anyway.

Donald Corenman, MD, DC
Moderator

February 9, 2015 at 11:23 pm

Post count: 8660

#12174

I have seen patients who did not have leg pain prior to a surgery develop leg pain after due to the retained pars fragments. That is not always the case and remember that I have a reputation of seeing patients with failed prior surgeries. The ones that did well would not obviously come to see me after a successful surgery.

Nonetheless, it makes no sense to me not to decompress the nerve roots. In addition, the pars fragments make excellent bone graft which is the requirement for a good fusion in the first place.

Neurosurgeons who think TLIF cages are “not big enough” have never performed a TLIF. They are speaking from inexperience. I have a 99% fusion rate and I would like to see the ALIF surgeons demonstrate a rate close to that.

When a TLIF is performed, the entire nucleus and cartilagenous endplate is removed. This allows the bone graft and BMP to fully engage these bone surfaces. BMP mixed with autograft (your own bone) goes in the front of the disc space. The TLIF cage with only autograft goes in the back of the disc space.

When you remove the pars defect, there will always be a spur that develops off of the pedicle. This spur grows into the nerve root and is the primary cause of nerve compression in this disorder. Removing the pars defect and then this spur decompresses the root (along with the placement of the cage to raise up the disc space).

The cages for PLIF first started about 15 years ago. At this point they were metal (Moss Miami cages). The PEEK cages started to be used somewhat later and the TLIF technique was started by Harms about 12 years ago.

I cannot recommend anyone in your area. It sounds like your research has been thorough.

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.

john123
Member

February 10, 2015 at 10:06 am

Post count: 30

#12183

Thank you very much for helping me to find a direction. This all makes perfect sense to me. I know people that have had fusion surgery that never fully recovered.

My only challenge at this point is finding someone locally that is as professional as yourself !
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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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