[Renee123]

#21738

What is the percentage of patients coming out of the TLIF surgery with residual leg pain that thy didn’t have before ?

I am referring to avg surgeons other than yourself that perform the same TLIF procedure. Some surgeons blame residual leg pain on BMP.

Is there anything that can be done during surgery to insure that nerve roots and other nerve fibers won’t be irritated?

You are barely retracting the thecal sac, correct ? Hoe could that even cause nerve pain ? By retracting the thecal sac ??

[Donald Corenman, MD, DC]

#21745

With a TLIF, you are retracting the descending nerve root. There is an 8mm space between the exiting and descending nerve root normally and the TLIF requires 12mm of space so you have to retract the nerve root about 4mm. I do this under a scope with my PA and I looking at the same highly illuminated field. He and I can both tell how much the root is retracted and we are very careful.

Yes, BMP can irritate the nerve root and this use to occur in my patients about 3% of the time. Due to technique changes and considerations, I have virtually eliminated that irritation.

I don’t think most surgeons use the microscope for a TLIF. I am not sure what their technique is without the scope.

Retraction can irritate the root and BMP certainly can.

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.

[Renee123]

#21753

1.) Does retraction of the thecal sack cause any kind of nerve pain ?

2.) What technique changes and considerations have you made so that BMP does not irritate the nerve root ?

3.) If a surgeon is not using a microscope, what could they possible be operating with, glasses ?

I just read an article on Beckers spine that for degenerative spondylolisthesis (I have isthmic), surgeons now only use BMP 7% of the time when doing a TLIF because of 1.) complications and 2.) cost.

It would seem if you are relatively young and a non smoker it might not be worth the risk of even using it. It accelerates fusion by how much? 5-10%?

[Donald Corenman, MD, DC]

#21759

Retraction of the thecal sack (and the nerve root within) can cause nerve injury and irritation. The nerve should be retracted gently and retracted parallel to the path that the nerve takes.

This is why I like the microscope. The microscope takes a 1/2 inch area, makes it as “big as a football field” due to magnification with high illumination and allows the surgeon and assistant to both view the same exact image.

I place only 1.5 to 2mg of BMP in the disc space, mix the BMP with bone (from the facet that was removed and moralized) then pack it in the front of the disc space. I then isolate the BMP by placing a “spacer graft” of a synthetic material (Mastergraft) behind the BMP and finally place a PEEK cage (Boomerang) filled with the autograft bone behind this mass in the back of the disc space. I have found this combination prevents nerve root irritation.

Surgeons who don’t use the microscope normally use their eyes or magnification loops (glasses with telescope lenses attached).

I think that BMP is used about 50% of the time if I would ask my own colleagues but that would not be a scientific poll.

In my experience, BMP increases fusion rate by 10%. That is, a fusion rate of 89% without BMP would be a fusion rate of 99% with BMP. As important, the speed to fusion is highly increased with BMP. A fusion that might take 10 months without BMP would take 5 months with BMP.

You must determine if BMP is right for you. If I was having my own back fused, I would have BMP used.

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.

[Renee123]

#21787

1.) How can complications be avoided with BMP when it is used for posterolateral fusion ?

2.) Can bone calcify and clog up the foramin and other nerve roots ?

3.) What dose would be used for just the posterolateral fusion ?

Most surgeons that I have met with say they only use BMP for revision surgeries and it is not worth the complications (and cost) the first time around.

This leads me to believe that they don’t use it very much at all unless they have to in revision, which means they don’t really know how to use it !

[Donald Corenman, MD, DC]

#21790

Posterolateral fusions really do not have a significant risk with BMP. If this is a fusion that does not take off the facet (as most posterolateral fusions do), I have yet to see a problem with BMP. As a matter of fact, the posterolateral fusions heal faster and more completely with BMP than the intradiscal fusions do.

Bone can “clog up” the foramen in a TLIF (but not in a posterolateral fusion) if not used properly. The dose for a posterolateral fusion only I am still working on but 2-3mg per level seems to be effective.

The complications of BMP use can be significantly ameliorated with the proper techniques.

BMP is not cheap but there is another way to look at its use. The cost to treat a pseudoarthrosis is well over $200,000 requiring at least another surgery and taking valuable time away from the patient who would be suffering in pain. With the use of BMP, I can reduce that non-union rate by 10% or one out of every ten patients. In addition, the time to fusion is only 5-6 months generally instead of 12 months which allows the patient to get back on track so much sooner.

My goal is faster and more complete fusion and BMP allows that to happen.

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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