Thoracic X-LIF Surgery

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Future Spine Surgeon
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December 9, 2012 at 1:06 am

Post count: 8

#7550

Hello Dr. Corenman,
I am a 20 year old female and I have been suffering from severe chronic thoracic spine pain since an orthopedic surgeon’s exam in April 2011. I have pain in the T7-8 region of my spine that radiates bilaterally to my ribs and sternum. I am extremely tender to touch in the area and have exacerbated pain with deep breathing and coughing. The pain is an unrelenting 10/10 and has not responded to any conservative treatments (medications, physical therapy, injections, scs trials, on-q pump trial, ect.). I have a 2mm central disc protrusion deforming the cord at T7-8, with very little myelopathy, and what my doctors believe to be DDD at the same level (as shown on MRI). There is no evidence of kyphosis or scoliosis. I have received many opinions from spine surgeons, and the latest recommends I undergo a T7-8 X-LIF. I can’t seem to find anyone who has undergone this surgery and I am worried about the risks and the recovery. If you’re familiar with this procedure, could you please tell me how you would prepare one of your patients for the surgery/recovery? I’m also wondering if you believe a discogram would be helpful in confirming the etiology of my pain? My doctors admit openly that they have never encountered a case like this with such unrelenting pain. I am trying to make the most educated decision regarding further treatment, and I would truly appreciate any help you could offer.
Thank you

Donald Corenman, MD, DC
Moderator

December 9, 2012 at 10:40 pm

Post count: 8660

#7556

Severe unrelenting pain in the thoracic spine that is recalcitrant to conservative care is a real problem to surgically treat. Pain can be generated from the disc, facet, rib articulation or by neuropathic means (more on that later). Cord compression typically does not cause pain as the cord does not contain pain receptors. The small herniation at T7-8 by itself is probably not causing pain but by definition, that disc is degenerative (you need to tear the disc through and through to produce a hernation).

If you have not undergone facet blocks, that would be my next step if I had a patient like you. The facets can cause pain and the “fix” is rhizolysis (see website), not a surgical procedure.

Finally, if nothing else works, I would consider discograms (see website). This test can identify the pain generator or generators. Also, if there is no pain reproduction, you have to go back to the drawing board and figure out which structure is really causing the pain.

The one caveat in this surgical discussion is the possibility of neuropathic pain (see website under “chronic radiculopathy”). That is pain caused by injury to the nerve itself and not originating from any mechanical structures. There is really no test that can identify this problem. It is a diagnosis of exclusion. That is, we surgeons do our best to identify the pain structure, perform the correct surgery and wait for the results. Thank goodness neuropathic pain is uncommon but is one source of poor surgical results.

The XLIF for the thoracic spine is a good procedure if necessary but you may not need this type of surgery. The XLIF is designed to remove the hernation but requires a portion of rib removal and an anterior approach (through the side of the spine). It is less invasive than the older approach but patients can still develop something caused intercostal neuralgia which is rib pain that can linger.

I would say that you need to identify the pain source before you consider a surgical procedure.

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.

Future Spine Surgeon
Member

February 5, 2013 at 5:20 am

Post count: 8

#7916

I am scheduled to undergo a T7-8 x-lif next Tuesday (Feb 12th). I was wondering if it is possible to use an On-Q Pump in an x-lif incision? My doctors know my post-op pain will be close to impossible to control and I suggested an anesthetic pump as an alternative to IV narcotics. But my surgeon said he has never used one before and wasn’t sure if it was possible for this approach. I’m not sure if you’re familiar with On-Q pumps or use them in your patients, but I would value any thoughts you have.
Thank you!

Donald Corenman, MD, DC
Moderator

February 5, 2013 at 8:30 pm

Post count: 8660

#7919

The On-Q pump continuously infuses anesthetic in the immediate post-operative period to reduce pain. Just like any “helpful tool”, there are benefits and risks too. This pump may reduce the post-operative pain but there are some questions of having a catheter in place for a period of time that might also be a tract for bacteria.

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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