Treatment options for failed C5-C6 cervical fusion (Cloward method)

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emonaco
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October 6, 2014 at 1:40 am

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#11497

(Patient info: 33yr female in otherwise good health whose profession is veterinary medicine)
I underwent surgery at the Denver VA January 2013 for an anterior C5-C6 discectomy and fusion. The surgeon employed a modified Cloward technique using an allograft (not sure of the source). Despite strict adherence to post surgical instructions, my fusion failed. My cervical ridiculopathy has not returned but the neck and shoulder pain returned about 7 months after surgery (5 months after I got out of the c-collar). In May 2014 I started being worked up for the recurrence of my neck pain. Survey radiographs were taken in May followed by an MRI in June and a contract CT in July. I met with a VA neuro-surgeon, who no longer performs surgery due to his advanced age, that confirmed that my fusion has failed and recommended undergoing a second surgery to have a titanium plate affixed at the C5-C6 level to correct for the cervical instability. There have been some mild to moderate changes to the articular facets at C5-C6 and mild degenerative changes noted at the levels above and below.

My question for you is whether or not there are other options for correction that I might find outside of the VA health care system (less invasive or artificial disc)? I understand that definitive answers/recommendations are not possible without seeing the imaging yourself. Just want to know what to investigate and if it is worth looking outside the VA.

Donald Corenman, MD, DC
Moderator

October 6, 2014 at 8:31 am

Post count: 8660

#11498

Pseudoarthoses are not uncommon with ACDFs- especially with allograft (cadaver graft) and with the older Cloward technique. You do have to make sure that your pain originates from the pseudo (there could be other pain generators).

If your pain is from the pseudo, then you could be a candidate for a repeat ACDF with autograft, consider allograft again or have a posterior fusion which generally causes the front to fuse also. An artificial disc replacement would not work in the face of a non-union.

It might be worth looking outside the VA.

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.

emonaco
Member

October 7, 2014 at 5:29 am

Post count: 2

#11502

Thank you for your quick response. The symptom that concerns me the most is a burning sensation that is focused over the region of C5 to T3 vertebral spinous processes and extends laterally (left and right) about 3 inches (totaling about 6 inches in width centered over posterior midline). This symptom was not present prior to surgery. The pain this worse later in the day, especially when I’m typing med records. When I pull my chin back while keeping my head level (posterior movement of my neck without extension), I do feel a bit of grinding with a popping-like sensation (similar to the sensation felt during a chiropractic adjustment). This movement is non painful and occasionally provides relief of generalized neck discomfort. There are no active or passive neck movements that elicit tingling, numbness, or radiating pain. ROM is slightly decreased on left rotation and left lateral flexion, but is otherwise normal. All but the above described burning sensation can be controlled with regular medical massage, NSAIDs, and occasional muscle relaxers. Using my medical understanding of neurology and pain pathways, there does not appear to be evidence of static or dynamic spinal cord or nerve root compression. The burning pain would be classified as neuropathic pain, possibly a result of scar tissue, bony changes of cervical articular facets, or other irritation of dorsal spinal nerves. Please correct me if I’m wrong or missed something. I’m not crazy about undergoing surgery again and the neurosurgeon said I could wait awhile. His primary concern was more with the potential consequences should I sustain a trauma like being in a car accident. In your opinion, does postponing surgery advance the progression of degenerative cervical changes and increase the likelihood of needing additional fusion surgeries in the future? Also, in your experience do patients have a more difficult recovery associated with a posterior fusion? With complete understanding of the limitations of any opinions offered in this forum, how would you rank the surgical options for correction?

Donald Corenman, MD, DC
Moderator

October 8, 2014 at 11:36 pm

Post count: 8660

#11505

Your spine is probably stable with a pseudoarthrosis. The pain you currently suffer from is most likely from the lack of union of this level. It is called sclerotomal pain and refers to the inside shoulder region commonly. This pain is quite commonly misdiagnosed as thoracic region generated pain when most of the time, the pain is really generated by the cervical spine.

WIthout seeing your X-rays and MRI, I can only speculate but I would generally repair this from the front. A posterior fusion is just fine but you would be in a collar for 8 weeks when an anterior fusion would have you in a collar for generally 1-2 weeks.

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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