To be microdiscectomied or not to be?

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derrick004
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October 5, 2012 at 5:08 am

Post count: 3

#7108

Thank you Dr. Corenman for this invaluable website for people like me thats been suffering for years of debilitating back pain. Been lurking around here and finally posted something . Not a stranger to back problems, having it for the last 25 years off and on. Seven years ago, I was diagnosed with a DDD. Epidural injections are the only thing that works for me. I get it about once a year (series of 3 shot), it gives me about 10 months to about a years worth of pain relief. I got 2 MRIs total, heres the latest.
MRI FINDINGS
Degenerative disc disc is present at L4-5. L4-5 contains a small posterior annular high intensity zone. Disc height loss is most prominent at L5-S1 whre discogenic endplate changes are present. the vertebral bodies are maintained in height and allignment. The conus is normal caliber and signal.

At L2-3,L3-4 and L4-5, there is no significant central canal or neural foraminal narrowing.

At L5-S1, a 5-6 mm right paracentral disc protrusion causes narrowing of the subarticular right lateral recess and probably abuts the traversing right S1 nerve root. There is no significant neural foraminal narrowing.

Doctor Corenman in your experience, would it be the size alone be indicative of a microdiscectomy?. The reason I ask is, the ortho that i saw 7 years ago did not want to operate because it was a small herniation(5-6 mm). In hindsight I’m kinda happy he didn’t operate on me right away. Secondly, How safe is epidural to your spine? I’ve been doing this for the last 7 years (21 total shots to the back) so far been lucky that it’s still working and the only thing that works. I get the L5-S1 transforaminal epidural to the right and sometimes bilateral.Thirdly I’m considering surgery (microdiscectomy) , The thing that stop from having one is that I read somewhere that microdiscectomy is not indicative for back pain but for leg pain. Is this true compared to your experience? My pain is in mainly the buttocks, lateral to my sacrum. I also lean to my left side about 25 degrees and and bend forward . Recently, I’m having a very little foot numbness. It’s the lateral side of my right foot, and sometimes when i wear socks I would feel my pinkie toe having a little spasm, very minute no pain at all, Back 100% Leg 0% (Pain distribution). Dr. do you think my L4-L5 is also a pain generator by just looking at the MRI results? When I get this episode of flare up because of the cortizone wearing off, it’s a hellish life. I’ve been very good with timing it . When I feel it coming, I’ll just call my pain management office and schedule for some shots. I can’t keep doing this forever tho. Dr. do you think I will benefit from a microdicectomy. My family, friends tell me not to have surgery because I will get worse,but there not the one living with this pain. By the way Dr., I have not seen any spine specialist since 7 years ago. Sorry for this long post, hope I don’t bore you with my life story. Thank you for your patience and thank you also for a speeedy response.

Donald Corenman, MD, DC
Moderator

October 5, 2012 at 8:48 pm

Post count: 8660

#7111

You have 100% sacroiliac pain or pain lateral to the sacrum without leg pain. You do not mention lower back pain (area around the “small of the back” in the center of the spine at the beltline). You do not mention what side the sacroiliac pain is focused on. Is it right sided only or bilateral?

Sacroiliac pain is the one area that can have multiple origins. This includes disc pain, nerve pain, facet pain, and sacroiliac joint origin in the order from most common to least common origin. However, buttocks pain (lower than the sacroiliac joint) commonly originates from nerve root compression.

You have disc height loss with endplate changes at L5-S1. This most likely is “isolated disc resorption” (IDR) and one of the most common origins of back and sacroiliac pain. You also have a disc herniation at L5-S1 on the right causing some compression of the S1 root. This too can cause right sided sacroiliac pain and more commonly causes buttocks pain. The facet cannot be ruled out as a pain generator by your description.

I am unclear regarding your leaning position; “I also lean to my left side about 25 degrees and and bend forward”. Is this a posture you assume to relieve pain or a position you are locked into (a list)?

In general, sacroiliac pain or/and buttocks pain originating from the spine can be disabling and incapacitating but generally is not dangerous. If you can manage with the epidurals, that is not a bad way to go. I have patients out 15 years continuing to get epidurals with good success although these injections do become less effective over the years for many patients. I have seen relatively few problems with most patients continuing to obtain epidurals other than ineffectiveness.

The question you ask is whether a microdiscetomy will be helpful. For lower back pain, the microdiscectomy surgery is about 50/50 in regards to satisfaction after surgery. However, if the compression of the S1 nerve is causing SI or buttocks pain, the success rate for surgery is closer to 90%. This assumes that the SI pain is on the same side as the herniation and a selective nerve root block temporarily eliminates the pain.

If the disc degeneration of L5-S1 (IDR) is the cause of the pain, a microdiscectomy will not relieve the pain. The way to determine if the L5-S1 disc is causing the pain is with a discogram (see website). If the facet is causing the pain, facet blocks will reveal if this structure is the pain generator.

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.

derrick004
Member

October 7, 2012 at 12:19 am

Post count: 3

#7114

It is mainly low back pain, location would be the top half of the gluteus maximus, 2 to 3 inches lateral of my sacrum and 2 to 3 inches lower than my belt line. It is not in the center of the spine, the pain is deep down inside the muscle of the top half of my gluteus maximus. The pain is right sided only.

The leaning position is more of a posture to attempt to relieve the pain “I also lean to the left side about 25 degrees and bent forward. I don’t do it on purpose it just happen when the pain start. Laying down gives me a lot of relief specially when I lay down on my stomach , I can even do Mc Kenzie and try to exercise to alleviate some of the pain but it does not take the pain away.

Dr. Corenman, In your clinical experience, how long does a microdiscectomy give you pain relief? Isn’t microdiscectomy will eventually undermine your disc and eventually lead to all sorts of problem in the future, ” more microdiscectomy and or fusion “. I guess Dr. I’m just afraid of any kind of surgery.
I read somewhere in your Steadman Clinic website that you where originally from Southern California , Is there any doctor that you can recommend?, preferably L.A. area. Thank you again Dr. Corenman,

Donald Corenman, MD, DC
Moderator

October 7, 2012 at 6:23 am

Post count: 8660

#7116

Unilateral pain deep in the gluteus muscle is more likely radicular pain from a compressed nerve. The leaning position could indicate foraminal stenosis (see website for description) as this position opens the foramen. McKenzie exercises (back extension position) should not relieve your pain if this disorder is foraminal stenosis as this maneuver narrows the foramen or lateral recess even more.

The microdiscectomy is not the problem that “undermines” the disc. It is the original degenerative changes of the disc and the full annular tear that allows the nucleus to “squirt out” of this through and through tear. The real problem is related to genetics and activity.

I do not generally recommend other physicians as I do not really know the quality of their work. Ask around. Get some word of mouth recommendations. Look up the surgeon on the internet. Look at this site for questions to ask the surgeon.

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.

derrick004
Member

December 22, 2012 at 12:10 pm

Post count: 3

#7636

Hi Doc, a quick update of my condition. On sept. 9 , oct. 3 I had an epidural injection (transforaminal). It didn’t work as i hope it would, so I saw a local ortho and ordered an MRI.
MRI FINDINGS:

T12-L1, L1-2 the intervertebral disc is normal.

L2-L3,L3-4 the intervertebral disc, neural foramina and facets are normal.

L4-5 there is loss of disc signal without focal abnormalities. There is mild facet hypertrophy and foraminal stenosis.

L5-S1 there is loss of disc height and signal intensity with an irregular right sided disc extrusion which measures 14 x 6 mm in the axial plane x 10 mm in the sagittal plane. This compresses the right L4 root in the lateral recess. The exiting L5 root is not compromised. There is bilateral facet arthropathy.

IMPRESSION:
At L5-S1, there is a right sided disc extrusion compressing the right S1 root.

I told the ortho my medical history and he did some test on me and in a nutshell he recommended fusion surgery . He said for sure L5-S1 and he said he would do discogram on L4-L5 to see if it’ a pain generator. By the way Dr. Corenman he also offered laminectomy but mention that it might be a temporary fix because the disc is already extruded( IDR ). He also mention about Hybrid fusion, fuse lower level and do artificial disc on top. I was very shocked when i heard I needed fusion.
I did have another shot coming up on oct. 31. It was a facet injection ( Bilateral ) on L5. As soon as I got up , I felt a tremendous difference. Pain was gone. I was back to work the next day. Sad to say it didn’t last. Today is Dec. 21 I scheduled a second and third opinion. Dr. Corenman kindly advise me to what you would do if you were to operate on me? I hope you would be my 4th opinion.
Again Dr. Corenman, thank you.

Donald Corenman, MD, DC
Moderator

December 22, 2012 at 9:12 pm

Post count: 8660

#7637

I am confused. What are your symptoms? Do you have mainly back pain in the center of your back, mainly right leg pain or some combination of both?

By your MRI report, it appears you have a large right sided L5-S1 herniation compressing the right S1 (not L4) root. You also have degenerative disc and facet disease of the L4-5 and L5-S1 levels.

If your pain in mainly right buttocks and leg pain, you most likely would be a candidate for a simple microdiscectomy only. If you have back pain greater than leg pain and you received great temporary relief from your facet blocks, you might be a candidate for facet rhizotomies. Fusion is only for chronic lower back pain that prevents most desired activities and whne conservative measures fail (see section “When to have Lower Back Surgery” on the website).

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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