weakness in levels above TLIF

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MASpinept
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June 23, 2021 at 8:01 am

Post count: 17

#34157

Hi Dr. Corenman,

I’m hoping to get your opinion on my latest situation; i had posted a few questions in the fall/winter in regards to my L5-S1 TLIF recovery, since that time i have been doing a lot of rehab, strength training and exercise to try to get my legs (and whole body) back into athletic shape. I have achieved this in all areas except on the right lower side. Prior to the fusion i had 2 failed right sided hemilaminectomies for occlusion of the L5 and S1 nerves, the surgeries led to spondylethesis which was repaired during the TLIF. At some point (not sure if this was present prior to surgery or if it was after) i started noticing my right hip and muscles of the upper leg felt weak, i did bring it up to the surgeon but he said the post op MRI looked clean; no neuro exams have been done by the surgical team since the surgery d/t covid (telehealth follow ups). So fast forward to current times, i returned to physical therapy, someone who did a very thorough neuro eval, and he agreed that many muscle groups on the right side going up as far as L1 are weak with a comparison of 4/5 on the right to 5/5 on the left. Once again i brought this to my surgical team’s attention and pushed for further work up to be done. I have an appointment with the physiatrist tomorrow, who is part of the spine group where my neursogeon is. I had made this appointment to get their opinion on the state of my leg and to see if any supports/bracing would be needed as the weakness very much affects my biking, running, swimming ability by fatiguing easily. I find i cannot feel certain muscle groups when i work out or when i am planting my foot down/rotating my leg. I have asked for an EMG to compare to the one done from last year prior to the TLIF, though i am not sure they looked beyond the levels of L5/S1. I do have some scoliosis but it hasn’t come up as an issue with the surgical team. My latest xrays show that the fusion is progressing exactly how it should be at this time, per the surgeon. There is some atrophy in the right leg as well. The response from the surgeon was basically lets see what the physiatrist says and then we will go from there.

I’m wondering if you have any thoughts as to what could be cause issue to develop on one side at higher levels than the fusion. I have tried to be patient and do everything possible to get myself in the best physical condition possible but i am again growing concerned. I’m only 34 and i’m nervous that things may have snowballed, i work in healthcare and i see many things that get brushed off or go unnoticed and i’m not interested in having this happen to me as i feel it with further any degree of disability.

What do you think? Many thanks in advance for being such a wonderful source of guidance and information.

Donald Corenman, MD, DC
Moderator

June 26, 2021 at 9:27 am

Post count: 8660

#34164

“I started noticing my right hip and muscles of the upper leg felt weak, i did bring it up to the surgeon but he said the post op MRI looked clean; no neuro exams have been done by the surgical team since the surgery…..Prior to the fusion i had 2 failed right sided hemilaminectomies for occlusion of the L5 and S1 nerves. The surgeries led to spondylethesis which was repaired during the TLIF”.

The levels of nerve compression were of L5 and S1 roots. The L5 root connects to the gluteus medius and sometimes glut max muscles, both highly important in walking and biking. If the medius is weak, you cannot lift up your pelvis on the opposite side when weighted (walking-called a Trendelenberg gait) and if the maximus is affected, your down pedal stroke would be less powerful on that side.

An EMG and consult with a neurologist would be helpful. I assume your new imaging demonstrates no further compression.

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.

MASpinept
Participant

June 29, 2021 at 10:04 am

Post count: 17

#34172

I actually have not have an imaging recently, the last MRI was about 11 months ago. I did see the neurologist today and he felt based on the exam there could be some adjacent segment issues. He is ordering an MRI and will do an EMG. Does ASD happen this quickly? I’m wondering now if another surgery is in the near future. Thanks

MASpinept
Participant

July 10, 2021 at 1:33 pm

Post count: 17

#34192

Hi,

Below are my ct results. Is this typical for 11 months post tlif? My pain continues to be an issue, most right leg pain and it is almost as bad as it was pre surgery. I also have more noticeable bilateral leg pain and numbness/tingling. It seems like as the weeks go on activities that were once tolerable are becoming more painful (swimming, biking, driving). I have an mri and emg next week. Thanks
Document: CT LUMBAR SPINE WITHOUT
PROCEDURE: CT 0054 CT LUMBAR SPINE WITHOUT CONTR Jul 9 2021 11:29AM
CLINICAL INDICATION: ENCOUNTER FOR FOLLOWUP DOSE: dlp; 768.87
CLINICAL INDICATION: Postoperative follow-up. Status post TLIF on 8/5/2020 with worsening back pain, right worse than left leg pain, bilateral leg numbness and tingling with standing, and worsening of symptoms with activity per the patient questionnaire.
TECHNIQUE: Helical CT of the lumbar spine without contrast was performed according to routine protocol. The helical data set was reformatted in the sagittal and coronal planes. Additionally a 3-D model of the data set was performed at an independent workstation. Dose reduction techniques were utilized including mA and/or kV adjustment.
COMPARISON: Lumbar spine radiographs from 8/7/2020 and 4/20/2021. Lumbar spine MR from 8/21/2020.
FINDINGS AND IMPRESSION:
Intact L5-S1 fixation construct in place with bilateral pedicle screws, vertical rods, and interbody device. No significant periprosthetic lucency to indicate component loosening.
At the left L5-S1 facet joint, there is bony bridging that appears to be progressing towards osseous union. No joint gas to suggest excess motion. No posterolateral osseous union on the right.
At the L5-S1 disc space on the right, there is bony spicule formation that may span the entire height of the disc space. There also appears to be developing bony bridging at the site of the interbody device, although hardware related artifact precludes accurate assessment. No intervertebral disc gas to suggest excess motion.
Vertebral body heights are preserved.
Alignment is maintained.
Disc heights are preserved at the noninstrumented levels.
T12-L1: No significant abnormality. Canal and foramina are patent.
L1-L2: No significant abnormality. Canal and foramina are patent.
L2-L3: Mild facet degenerative change bilaterally. Patent canal and foramina.
L3-L4: Mild right facet degenerative change. Patent canal and foramina. L4-L5: Shallow posterior disc bulge. Mild left facet degenerative change.
Patent canal and foramina. Page 1 of 2 L5-S1: Status post bilateral pedicle screw fixation and right-sided TLIF, Page 1 / 2
as detailed above. Canal and foramina are patent.

L3-L4: Mild right facet degenerative change. Patent canal and foramina.
L4-L5: Shallow posterior disc bulge. Mild left facet degenerative
Patent canal and foramina.
L5-S1: Status post bilateral pedicle screw fixation and right-sided TLIF, as detailed above. Canal and foramina are patent.
Postoperative changes at the dorsal soft tissues. Imaged retroperitoneum is unremarkable.
NUMBER OF IMAGES: n

MASpinept
Participant

July 21, 2021 at 7:29 am

Post count: 17

#34197

Hello again,

I wanted to give an update; the MRI didn’t show any stenosis or compression, just further arthropathic changes on L4-L5 (right above the tlif) with new bilateral effusions. Unfortunately i have not been able to get an answer regarding the fusion status, the only answer i received was that the hardware shows no signs of loosening. I’m just a little concerned because based on my research there should be more of a solid fusion by the 1 year mark (BMP was used). I’m starting to think there may be some malalignment since so many of my symptoms are positional and activity related, prior to the TLIF i did have a slip with a pars fracture on the right side of L5. I do have mild levoscoliosis in the lumbar spine, have been told i only have 4 lumbar vertebrae, and immediate post op images from the tlif last year commented on stepwise lethisis of the L spine (particularly retro at L4-5) but again all this structural information has been brushed off as a reason for any symptoms since surgery. I have an EMG scheduled for next month. Please let me know your thoughts on this when you get a chance. I do think i would like to schedule a long distance consult/review with you in the near future once we get the EMG results and the neurologist’s thoughts. I’m wondering if ortho spine would have more of a focus on spinal structure vs only looks for for nerve compression. Thanks for your time!

Donald Corenman, MD, DC
Moderator

July 21, 2021 at 3:50 pm

Post count: 8660

#34201

Its surprising that the radiologist did not comment on fusion status with a CT scan. They might not comment if it was an MRI but a CT scan tends to be definitive. What are your current symptoms? See: https://neckandback.com/conditions/how-to-describe-your-history-and-symptoms-of-lower-back-and-leg-pain/.
A long-distance consultation might be necessary.

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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