Surgery?

Tagged: Degenerative facets and relationship to isthmic spondylolisthesis

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Jinx
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December 15, 2017 at 4:20 am

Post count: 8

#27047

Hi Dr Corenman.
I had xrays done in 2015 that showed pars fracture, hypertrophy, LSTV lumbarised S1, facet joint arthropathy. Ive had back pain with radiculopathy down to the knee for about 8 years. It is unrelenting and is causing problems with sleep, standing, sitting too long lying down and walking too far.

I had MRI done recently. The results as follows

L1/2 No significant Disc abnormalities. No significant facet joint arthropathy.

L2/3 Mild loss of invertebral disc signal. No focal posterior disc protrusion. Annular tear anteriorly. Facet joints unremarkable.

L3/4 Mild loss of invertebral disc signal and height. Annular tear anteriorly. No focal posterior abnormality. Mild facet joint hypertrophy. No significant joint effusion or periarticular oedema.

L4/5 Moderate loss of invertebral disc signal with miminum loss of disc height. Posterior disc bulging. Right foraminal exit zone and far lateral shallow disc protrusion potentially irritating the exiting right L4 nerve root. Neural foramen midly narrowed but no definite compression. Bilateral facet joint arthropathy with joint effusion, bony and capsular joint hypertrophy and some minor periarticular oedema present bilaterally. This is more marked on the right. There is some sclerosis across the pars interarticularis region but no definitive MRI evidence for significant chronic pars defect. No significant oedema.

L5/S1 No significant disc abnormality. No significant facet joint arthropathy.
The distal thoracic cord and conus are normal in appearance. No vertebral or paravertebral abnormality.

What do you feel would be the best way to approach these issues. I have a significant hypertrophic bone mass on tbe right side of L4/5 that is immediately noticeable on xray. And apparently a far lateral and posterior bulge with a few annular anterior tears
I have had enough of the pain now. I need to know what I should be asking for. I cant keep taking anti inflams theyre causing stomach pain and Ive already had an erosion of the esophagus. Ive been in pain a long time. :(

Thanks for your comments. And your advice.
I appreciate your time

Donald Corenman, MD, DC
Moderator

December 16, 2017 at 10:01 pm

Post count: 8660

#27067

First, we have to define your symptoms. See the section on symptom description to fully understand how to convey your pain. https://neckandback.com/conditions/how-to-describe-your-history-and-symptoms-of-lower-back-and-leg-pain/

This radiologist does not note pars fractures. He does not spot the transitional vertebra either. He does note the pars is intact (“there is some sclerosis across the pars interarticularis region but no definitive MRI evidence for significant chronic pars defect”) so we know he was looking for this.

You have significant degenerative facet disease at L4-5 (“Bilateral facet joint arthropathy with joint effusion, bony and capsular joint hypertrophy and some minor periarticular edema present bilaterally”) so this means two things. A degenerative facet level normally has intact pars as pars fractures would “disconnect” the facets which would prevent degenerative changes. Also, this substantial degenerative facet change could indicate instability of this level which might only show up on flexion/extension X-rays.

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.

Jinx
Participant

December 17, 2017 at 1:21 pm

Post count: 8

#27085

The xrays from 2015 are here.
Xrays
Is it possible that I have healed pars fractures considering the sclerosis/hypertrophy.
My pain is aching pain across the lower back with deep gnawing pain through the buttock and hip which radiates down my leg around the front of my knee.
If i flex and arch my back with my hips i get sharp pain in the back, and I can get electric shock type pain that shoots up my spine that makes me squeal. My pain is worst at night. Its gnawing dragging down the leg and relentless. In the morning i ache and cant stay in bed i have to move to get to more comfortable levels. I have on occasion had my leg give way. When i get into the car there is loading and unloading of the spine pain that makes me groan.
I have pain 24/7.

Do i need to bring up why the LSTV was not mentioned?
Are the levels numbered wrong on his report??

Thank you Dr Corenman I really do appreciate your time.

Jinx
Participant

December 17, 2017 at 2:36 pm

Post count: 8

#27087

Oh and also if the annular tears are anterior can they be causing pain. I do have some milder pain at higher levels.

I just generally hurt all the time from my bra level down to my knee, but its more intense around lower lumbar spine especially through the buttock hip and down just past the knee. It can be very miserable especially with prolonged activity.

Donald Corenman, MD, DC
Moderator

December 17, 2017 at 3:52 pm

Post count: 8660

#27089

I would assume that you have dynamic foraminal stenosis (stenosis that occurs when you stand and walk). I cannot open your x-rays due to viruses. Your pain with transitions (“When i get into the car there is loading and unloading of the spine pain that makes me groan”) is probably due to instability which fits with severe degenerative facet disease. You also might have a dysplastic spondylolisthesis from chronic fracture/healing which elongates the pars and acts like a degenerative spondylo.

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.

Jinx
Participant

December 18, 2017 at 1:45 am

Post count: 8

#27093

Thank you Dr Corenman. I will be seeking a second opinion from a new surgeon shortly once my sports doctor refers me in a couple of days time and I will use your pain questionaire to relay my pain appropriately and I will ask questions relating to potential stenosis and the pars issues as well as my Transitional level coming into play.
I will let you know of the outcome.
Thanks for your valuable insight and help. Your site is a wonderful resource.
Kind regards :)
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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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