Surgical options when pain is confined to the lower back?

Tagged: Surgery for lower back pain

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aprinciott
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October 23, 2016 at 1:12 am

Post count: 1

#23246

I have been suffering from semi-debilitating low back pain for the past 5 years, The back has always been located in the same spot: right posterior near L5-S1. I’ve never had any leg pain. This is the result of a re-injury. In the summer of 1999, I was doing some Yoga, reached with my right hand towards my left foot (feet were spread apart), and felt some strain at the spot described above, Within a few hours the pain was considerably more intense, with sitting being particularly painful. The problem took about 8 months to resolve.

The re-injury occurred in late 2011 as a result of lifting and pushing a box that was too heavy for me to manage. Same spot, with sitting again being quite painful. X-rays and CT scans have been normal, and MRI showed small disc bulges at L4-L5 and L5-S1, the clinical significance of which was determined by the radiologist to be uncertain.

I live on the Vermont/NH border(close to Dartmouth College), and the prevailing treatment philosophy regarding back problems is conservative to the point of seeming surgery-averse. At this point, I’ve exhausted all the conservative treatment options, seeing between 35 and 40 different (and seemingly expert) practitioners to try Physical Therapy, Chiropractic, Acupuncture, Pain Medications, Injections, Prolotherapy (both the standard and platelet-rich plasma varieties), Pilates, Deep Tissue Massage and other treatments I’m probably forgetting at the moment. Some of these treatments simply inflamed the problem temporarily, while others had no effect whatsoever. In every instance, the treatment ended up seeming irrelevant to whatever mechanism is causing my pain; the analogy I’d make is having a problem with a car’s engine and addressing it by working on the electric system.

I’ve heard a lot about how any sort of back surgery can start a sort of “cascade of horrors” that leaves the patient even worse off than they were. I’ve also heard that when back surgery is successful, it’s usually because it relieved radicular leg pain, and that the success rate of surgery to address pain confined to the low back is not high.

I’ll admit that as a lay person, this all seems very odd. I can point to exactly where I hurt, it’s a very small spot, and this has always been the case. It seems that there must be a simple mechanical problem at this spot, and that there should be a way to fix the mechanism directly with some sort of surgical procedure.

Have you ever had a patient with a problem this localized who was successfully treated with surgery?

Donald Corenman, MD, DC
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October 23, 2016 at 7:41 am

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#23250

The specialists at Dartmouth are famous for disliking surgery for lower back pain. The surgical treatment for lower back pain generally has good results if you have the “right” pathology and you are a good candidate for surgery.

If you have significant degenerative disc disease, have failed conservative measures (as it appears you have) and have a surgical workup that confirms the disc or discs are pain generators, you could be a candidate for a fusion of the one or two levels. The success rate for this type of patient is 90% for 2/3 relief of lower back pain. The workup might just be a history and physical examination along with imaging studies (IDR of L5-S1 only) up to blinded lumbar discograms.

The understanding for these patients post-op is that the same genetics that caused the initial one or two discs to tear and become pain generators still exists with the upper lumbar discs. That is, if the pain is mostly gone after surgery, this does not mean that this individual can go back to ditch digging or heavy lifting. Surgery eliminates pain but does not allow this individual to return to “bump skiing” or squats at the gym. The “normal” discs have to be respected so as to prevent future injury.

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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