too young for fusion, need an alternative

Tagged: Coflex, fusion alternative, snowboarding, Spondylolisthesis, Synovial cyst

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snowbunnie
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January 21, 2020 at 1:16 pm

Post count: 1

#31955

Dr. Corenman,
First of all, your website is wonderful. You explain things so well.
I have a very important decision to make regarding the future of my spine and I would appreciate your advice. I will try to be brief with my history.
I am 42, female, BMI 26 and very muscular, highly active in extreme sports most of my life – snowboarding, volleyball, wakeboarding, paddleboarding, surfing, kickboxing, and recently retired from roller derby. I have had multiple injuries over the years, but with chiropractic care, stretching, and exercise I have maintained good spine health. In Oct of 2019 I started to experience debilitating sciatica of my right leg with numb toes and leg weakness, but zero back pain. An xray showed less than grade 1 spondylolisthesis of L4 over L5 and a herniated disc was suspected, so I tried a bunch of conservative care treatment but my symptoms continued to get worse. I am currently functional only with narcotic pain management. When I finally had an MRI the 1st week of Jan 2020 my discs look great, but I have a large synovial cyst on the ligamentum flavum that is impinging my L5 nerve root. I met with a physiatrist who said the cyst cannot be aspirated and referred me to a neurosurgeon. The neuro said the cyst has to be surgically removed and in doing so he will have to remove a piece of bone that will weaken my otherwise healthy spine. He is recommending a fusion to stabilize the spondy and says if we do not stop that abnormal movement the cyst will likely return and the spondy will progress.
Of course I have read all the horror stories about the domino effect of fusion so I am terrified. If I fuse my L4-L5 will I be able to continue to snowboard and play volleyball? I absolutely cannot become sedentary. I do not know quite how to explain this, but without my sports, I do not think I would want to continue living. I know that sounds dramatic, but staying active is the only good way I have found to battle depression.
I know I have to have the cyst removed, but I have to decide if I want the fusion done at the same time. My questions are: What do you think about continuing my normal activities without a fusion? Will the spondy progress and will the cyst return? What if I have the fusion and continue my normal activities? Will I be able to avoid the adjacent segment problems that I keep reading about, say by keeping my core super strong or wearing a brace? Does the fact I am young, strong, and have an otherwise healthy spine change the outcome of a fusion, say in comparison to someone with a bunch of already existing degenerative issues?
I know your opinion of things like Coflex device because I have read a bunch of these forums. I notice that most of the people asking about it have disc problems so what you are saying make sense. But do your feelings about the Coflex device change at all in a situation like mine, where my discs are healthy and where the sole purpose is to stabilize a spondy? Is there another device or fusion alternative you can recommend that will allow me to keep snowboarding to a ripe old age?
I have an appointment scheduled for Jan 27th with a surgeon that uses the Coflex device, and also just to get a second opinion. I would greatly appreciate your advice before I make a decision that will affect my entire life so much. Thank you so much.
Cari

Donald Corenman, MD, DC
Moderator

January 22, 2020 at 8:02 am

Post count: 8660

#31958

You note that “Oct of 2019 I started to experience debilitating sciatica of my right leg with numb toes and leg weakness, but zero back pain. An xray showed less than grade 1 spondylolisthesis of L4 over L5 and a herniated disc was suspected”.

You then note “MRI the 1st week of Jan 2020 my discs look great, but I have a large synovial cyst on the ligamentum flavum that is impinging my L5 nerve root”.

Then finally you note “The neuro said the cyst has to be surgically removed and in doing so he will have to remove a piece of bone that will weaken my otherwise healthy spine. He is recommending a fusion to stabilize the spondy and says if we do not stop that abnormal movement the cyst will likely return and the spondy will progress”.

One of the important factors is how stable (or unstable) this degenerative spondylolithesis really is. Stability is judged by flexion/extension X-rays and you don’t mention those. There are many degenerative spondylolitheses that produce ganglion (or synovial) cysts that are compressive to the nerve root. If your disc looks good and the spondylo level is stable on flexion/extension X-rays, you could have a simple cyst excision with the understanding that this level can go on eventually to need a fusion.

I do not endorse the Coflex device as this device will eventually fail and does not address the problem of cyst compression of the nerve root.

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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