Archives

Thanks Dr. Corenman,

After reviewing the forum more thorougly, I should also add:

1. I was fairly pain free prior to this event in January 2022. After my initial bracing as an 18 year old, I went on to play 6 years of collegiate and amateur rugby (maybe not the best choice). For most of my adult life, I’ve been very active; triathalons, century bike rides, mountain biking. Last fall, I was hiking up and down the mountains of the Rockies backpacking and hunting with no problems.

2. I have a fairly significant sitting intolerance. Where initially pain was felt in the gluteal region and R hip. I had difficulty with sit to stand. This gradually went away. Now, my foot issues appear to be amplified with prolong sitting.

3. Standing Lumbar flexion/extension x-rays showed no instability. “no evidence of instability during flexion and extension.”

4. MRI report:
a. L4 pars defect with at most minimal anterolisthesis. Some chronic, mechanical fatty marrow changes are present in the L4 pars interacriculari bilaterally. No bone marrow edema.
b. L4-L5: Diffuse disc bulge with questionable mild superimposed, broad-based central protrusion. No spinal canal or lateral recess stensosis. No formainal stensois. Mild facet arthropathy with trace effusions.
c. L5-S1; Small right central disc extrusion/protrusion abutting the traversing right S1 nerve root in the lateral recess without nerve displacement or lateral recess stensosis. No spinal canal or formainal stenosis. Mild facet arthropathy.

5.
a. Surgeon A plan (more specifically): “think the L5-S1 disc his main pain generator. Based on the central location and what appears to be conjoined nerve roots, I would likely do a laminectomy to see if we can unroof this and give him as nerves more space with a foraminotomy and medial facetectomy on the right side. If this did not help him, we would need did do more aggressive things and consideration for a fusion”

b. Radiology/pain management note: ” Imaging shows bilateral S1 nerve root contact and bilateral L5 nerve root contact as well as bilateral pars defect at L4″

Sorry, a couple more followup questions.
1. Would the conjoined nerve roots have a clinical significance.”
2. It seems to be there is some ambiguity in reading my imaging regarding nerve contact, is this normal?

After reviewing the forum more thorougly, I should also add:

1. I was fairly pain free prior to this event in January 2022. After my initial bracing as an 18 year old, I went on to play 6 years of collegiate and amateur rugby (maybe not the best choice). For most of my adult life, I’ve been very active; triathalons, century bike rides, mountain biking. Last fall, I was hiking up and down the mountains of the Rockies backpacking and hunting with no problems.

2. I have a fairly significant sitting intolerance. Where initially pain was felt in the gluteal region and R hip. I had difficulty with sit to stand. This gradually went away. Now, my foot issues appear to be amplified with prolong sitting.

3. Standing Lumbar flexion/extension x-rays showed no instability. “no evidence of instability during flexion and extension.”

4. MRI report:
a. L4 pars defect with at most minimal anterolisthesis. Some chronic, mechanical fatty marrow changes are present in the L4 pars interacriculari bilaterally. No bone marrow edema.
b. L4-L5: Diffuse disc bulge with questionable mild superimposed, broad-based central protrusion. No spinal canal or lateral recess stensosis. No formainal stensois. Mild facet arthropathy with trace effusions.
c. L5-S1; Small right central disc extrusion/protrusion abutting the traversing right S1 nerve root in the lateral recess without nerve displacement or lateral recess stensosis. No spinal canal or formainal stenosis. Mild facet arthropathy.

5.
a. Surgeon A plan (more specifically): “think the L5-S1 disc his main pain generator. Based on the central location and what appears to be conjoined nerve roots, I would likely do a laminectomy to see if we can unroof this and give him as nerves more space with a foraminotomy and medial facetectomy on the right side. If this did not help him, we would need did do more aggressive things and consideration for a fusion”

b. Radiology/pain management note: ” Imaging shows bilateral S1 nerve root contact and bilateral L5 nerve root contact as well as bilateral pars defect at L4″

Sorry, a couple more followup questions.
1. Would the conjoined nerve roots have a clinical significance.”
2. It seems to be there is some ambiguity in reading my imaging regarding nerve contact, is this normal?

Apologies, I left out an entire operation!

ANTERIOR

INCISION AND EXPOSURE: Following surgical time-out and radiographic localization, a 4 cm incision was made in the left flank over the L3-4 disc space in a transverse manner. Electrocautery was utilized to achieve hemostasis. Blunt dissection was utilized to dissect through the subcutaneous fat. With great care in the lumbar fascia was incised with Metzenbaum scissors. The external oblique, internal oblique and transversalis musculature was spread bluntly. The transversalis fascia was snipped and the retroperitoneal space was entered. Digital dissection was utilized to develop the plane lateral to the psoas and to reflect the peritoneal sac anteriorly. Retroperitoneal fat was gently dissected. The psoas muscle was palpated.

SEQUENTIAL TUBE DILATION: Sequential tube dilation was performed with the NuVasive NeuroVision system with triggered EMG hunting algorithms and fluoroscopic guidance gently spreading the fibers of the psoas muscle and docking on the left L3-4 disc annulus. A K wire was inserted into the left L3-4 disc annulus for stabilization. The Maxcess retractor also under triggered EMG and docked on the disc. This was also performed under fluoroscopic guidance. The lateral annulus was visualized. A hand-held EMG probe was utilized to confirm that no neurologic structures were within the surgical field. Microscopic magnification and microsurgical techniques were also utilized for hemostasis and to confirm that no neurologic structures were at risk.

EXPLORATION OF LEFT LUMBAR PLEXUS: The left L3 nerve root was visualized and explored status-post discitis with extradiscal and foraminal extension resulting in radiculopathy. Neuroloysis of the left L3 nerve root and lumbar plexus was performed utilizing surgical microscopy and microsurgical techniques. At the the completion of the this portion of the procedure, the L3 nerve root and component of the lumbar plexus was free of further compression.

ANTERIOR DISCECTOMY: An annulotomy was performed in the left lateral annulus followed by discectomy with pituitary rongeurs and Kerrison rongeurs. A sharp Cobb was utilized to elevate the cartilaginous endplates were well was left to them off of the cephalad aspect of L4 and the caudad aspect of L3. The remaining cartilaginous endplates were removed. There was no gross evidence of infection in this disc. Similarly, the bone was of good quality. Ring curettes and rasps were utilized to prepare the endplates with healthy bleeding bone.BONE MARROW HARVEST: 10cc of bone marrow was harvested from S1 utilizing a Jamshidi needle and syringe for autologous fusion purposes.

ILIAC CREST BONE MARROW HARVEST: A Jamshidi needle was inserted through a separate fascial incision and separate skin incision into the left posterior superior iliac spine. 5 cc of bone marrow was aspirated in order to combine with of ethos tricalcium phosphate allograft for fusion purposes.

ANTERIOR LUMBAR INTERBODY FUSION: An appropriate-sized NuVasive titanium cage was chosen with a 55 mm x 22 mm lordotic footprint 8mm cage chosen. This was filled with a combination of local autogenous bone graft saved from the endplate shavings, allograft with bone marrow aspirate and extra small infuse. The cage was then inserted under fluoroscopic guidance. Excellent distraction and fit was noted.