Surgical candidate?

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drbourque
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July 10, 2014 at 4:49 am

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#11173

Hello, Dr. Corenman.
I am a chiropractor in Louisiana and would value your opinion on my personal findings. I am a 5′ 7″ 197#, 44yoa white male with history of neck pain radiating into the right suprascapular, posterior scap and deltoid areas for the past month. Visible atrophy of the anterior and middle deltoid and biceps. Grade 3 motor deficit of middle deltoid, grade 3+ anterior deltoid and grade 4 biceps developed just prior to taking the MRI. No sensory changes (sharp and vibratory). No lower extremity involvement. No balance problems. No change in bowel or bladder function. History of medial and lateral epicondylitis on the right. Transient right interossei spasm with pinching or gripping at times. Left grip strength slightly decreased (15%). X-rays show mildly decreased lordosis, mild anterior weight bearing, moderate disc thinning with anterior osteophyes at C5-6. Multilevel uncinate hypertrophy. MRI 6/24/14 shows the following significant findings:
C2-3: No disc protrusion or central canal or foramen stenosis. The facet joints appear mildly arthritic.
C3-4: There is a disc bulge pattern. It extends dorsal to the disc space by 1mm. Moderate to severe bilateral foramen narrowing by uncovertebral hypertrophy. There is still trace CSF in the left root sleeve. The right C4 root sleeve is attenuated and CSF visualization. Mild DJD of the facet joints.
C4-5: There is central and paracentral to the right soft disc protrusion and osteophyte complex causing a tight right foramen stenosis. The cord is rotated counterclockwise but not compressed. The left foramen is patent. There is mild facet arthropathy.
C5-6: There is a disc bulge extending dorsal to the disc space by about 1mm. There is moderated left and more severe right foramen narrowing by uncovertebral joint hypertrophy. Mild to moderate facet arthropathy. The central canal is patent.
C6-7: There is a midline soft disc protrusion. It extends greater to the left and extends dorsal to the disc space by 4mm. I causes central canal stenosis, but no cord signal abnormality. there is narrowing of both foramen especially severe to the left by the disc protrusion and osteophyte and on the right less so by uncovertebral joint hypertrophy. there is facet arthropathy.
C7-T1: Within normal limits
No spondylolisthesis. No adjacent neck soft tissue abnormalities.

Treatment to date has consisted of Cox cervical traction, Graston of the cervical region and right shoulder girdle. Eye field exercises (pursuits and saccades), coupled reduction of C5 and C4, left cerebellar and right cortex stimulation according to exam finding from a Chiro Neuro (DACAN). Massage and trigger point therapy to splinted muscles in the upper thorax and cervical region. Cervical traction decompression in my office (which seems to give the most relief) two to three times per day. I also received an epidural steroid injection to C4-5 and C5-6 about a week ago. A prescription of gabapentin was given for the radicular pain.

Ranges of motion are improved, but still restricted. Right deltoid and biceps strength is improving slowly with strengthening exercises.

I have no other significant medical history.

I am scheduled to consult with three other neurosurgeons to discuss my options within the next couple of months. Could you determine from these findings, what surgical procedure, if any, would be recommended? And what are the recovery times for each? Obviously, I would rather not have surgery, if at all possible. Are there any minimally invasive techniques available for this sort of condition and what does the recovery entail? Obviously I am concerned about my ability to practice.

Thank you in advance for taking the time to read this post. Your input is greatly appreciated.

Donald Corenman, MD, DC
Moderator

July 14, 2014 at 1:40 am

Post count: 8660

#11178

Deltoid weakness is a C5 nerve root problem and C6 innervates the biceps muscle. You have significant C4-5 compression (C5 root-“tight right foramen stenosis”) and C5-6 compression (C6 root-“moderated left and more severe right foramen narrowing by uncovertebral joint hypertrophy”).

This requires some thought process to go through the various scenarios to understand what to do.

C6-7 is not wonderful as there is both foraminal and central stenosis. Unfortunately, your C3-4 level is very degenerative too.

Sometimes surgery is necessary even though we don’t want to consider it. Nerve compression that causes motor weakness is serious and might not be recoverable even with surgery. It is this situation that surgery needs to be considered to allow the best chance for recovery of motor strength.

Based upon your report, the two levels at C4-5 and C5-6 have to be incorporated in the ACDF as these levels cause your current motor weakness (C5 and C6 roots). It is important to free up the nerve roots to have the best chance to allow them to recover, especially with your occupation being a chiropractor.

The level at C6-7 is very degenerative and includes central stenosis as well as severe foraminal stenosis. I don’t think you can “park” a fusion on top of this level (C4-6 ACDF) without causing this level to become symptomatic. Therefore this level needs to be part of the surgery.

The flexion-extension x-rays would be important to know how much range of motion you have in C3-C7. If these levels are as degenerative on X-ray as on the MRI, there should be very limited range of motion. This is important as you are probably looking at an ACDF (fusion) of at least three levels and probably four.

The question is what to do about C3-4. This level does not contribute any motor nerves to the upper extremities so this level is not contributing to your weakness. Depending upon this level’s contribution to your current pain, it may or may not need to be addressed surgically. C3-4 can contribute to neck pain, especially due to the root compression (“Moderate to severe bilateral foramen narrowing by uncovertebral hypertrophy”). This can be determined by a selective nerve root block of C4 and a pain diary (see website).

If the C3-4 level is very stiff based upon the motion x-rays, surgically including it might not cause any significant problem to you in loss of range of motion. This does however mean a four level ACDF which will make your neck stiffer somewhat. You could continue your career but you might not want to consider a change in career to boxing or long distance running.

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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