Treatment for L5-S1 Spondylolisthesis

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Sally
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June 6, 2011 at 10:30 pm

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#4616

Hello Dr. Corenman,

I am a 55 year old female, very athletic. I have been diagnosed with a Grade 1 L5-S1 anterior spondylolisthesis with bilateral chronic pars interarticularis defects at L5. My symptoms are essentially all on my left side with pain in my lower left back and down to my left buttocks. I have no pain in the leg, but then extreme pain and discomfort (tingling/burning) along the outside of my left foot. My MRI shows that I have a stable grade 1 L5-S1 spondylolisthesis of approximately 3mm with evidence of bilateral pars inter articularis defects at L5 (L5 spondylolysis). There is no central or formainal stenosis from L1 through L5. There is a diffuse pseudo disc bulge but no central canal stenosis. There is a mild left side foraminal stenosis with contact with the exiting left nerve root.

I have received differing opinions as to surgical options. I have seen several surgeons who believe I should have a fusion with hardware. I am very concerned about this extensive surgery which could be more problematic because I have severe osteoporosis. I have also received the opinion that I could be helped by a foraminotomy of the left side without hardware. This would obviously be less invasive. I am wondering whether I truly need the more extensive surgery with hardware. I have seen several articles in the literature recently where patients with seemingly similar symptoms and defects to mine have been helped without hardware. Since my symptoms seem consistent with the left side foraminal stenosis, could the foraminotomy be sufficient for relieving the pressure on the nerve? Afterall, I likely lived pain free for years with the small instability and only likely developed the pain from the left side stenosis that developed. I realize you can not make a determination without an exam, but I would value your opinion and thoughts on my surgical options. I have had several series of steroid injections and they did not really help.
Thank you for your time.

Donald Corenman, MD, DC
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June 7, 2011 at 7:30 am

Post count: 8660

#4617

By your complaints, you have evidence of radiculopathy from foraminal stenosis which is a common sequela of an isthmic spondylolysthesis (see web site). However, you also complain of lower back pain which may be a sign of instability from the pars fractures. The fact that the lower back pain is only one sided may possibly be an indication of nerve irritability and not instability. The pain in the outside of the foot normally belongs to the S1 nerve root but would be unusual with an L5 isthmic spondylolysthesis, as this normally affects the L5 root. None-the-less, I have seen the L5 root occasionally cause this symptom.

The foraminotomy on the left at L5-S1 in the face of an isthmic spondylolysthesis can be problematic. The cause of the collapse and bone spur formation that leads to the nerve compression stems from the pars fractures and instability/ degenerative changes. Performing a foraminotomy can create further destabilization of the level.

In addition, if some of the pain is originating from your spondylolysthesis, foraminotomy surgery will not eliminate that pain. You can get an idea if most of the pain is originating only from the nerve by using a selective nerve root block (SNRB- see website). With great temporary relief- there is a reasonable chance that the pain is nerve only.

So to get to the point- foraminotomy can work to relieve leg pain but the chance of developing instability after the surgery is high and therefore, I personally don’t recommend it except in very special cases. The TLIF procedure for decompression of the root and permanent stabilization of the isthmic segment is most likely the procedure that has the best results for nerve pain from an isthmic spondylolysthesis. This procedure reconstructs the missing disc height and makes more room for the nerve. Yes- it is a fusion but this segment most likely has a degenerative disc along with root compression and pars fractures with possible instability.

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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