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#35119Topic: Update on back pain in forum BACK PAIN |
Hi Dr. Corenman,
I had a long distance consult with you a few months ago, it was very helpful; i am hoping you can provide some insight based on the latest information. It appears based on my CT that i finally have a solid fusion in 2/3 locations of the L5-S1 TLIF (performed in 8/2020). The fusion status was questionable until last week when the CT finally noted solid fusion on the left posterior and anterior interbody. I also asked my surgeon for flexion/extension xrays, the report only comments on the L5-S1 level and it notes no motion in this segment. Though this is good news, i’m having considerable pain. My surgeon was concerned about adjacent segment issues at the l4-5 level, i am waiting for a call with him to discuss the images and his thoughts on what to do so that is TBD.
My symptoms are very positional and activity based-i’m having a hard time even getting through an 8 hour shift at work. I try to rotate positions but standing gives me pretty significant, stabbing back pain (L>R) and sitting gives me leg pain. I do have chronic radiculopathy in L5-S1 but now i feel nerve pain going down the front of my leg through my knee. I do exercise quite a bit and depending on the form of exercise my sx are made worse-mostly it flares the sharp back pain. A more noticeable symptom of late is feeling like i need to roll my pelvis down to “open up” my lower back. I feel like i need to brace my back by engaging my core and forward flexing my hips. This is particularly noticeable when standing for a little while, its a bit hard to explain.
I had discussed having injections done at this level with the pain mgmt MD but he did not feel injections would be helpful in my lumbar spine because my back had been altered by surgery so much. He felt the issue was more structural and since i had no relief from a previous injection, and instead had many side effects from the type of steroid that was used- he did not think another injection would be helpful.
I’m wondering if you can look at the latest images and let me know your thoughts on the alignment of the lumbar spine and the level above my fusion.
Thank you
#35118 In reply to: Multiple Surgical Opinions |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?#35116 In reply to: Multiple Surgical Opinions |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?#35115Topic: Multiple Surgical Opinions in forum BACK PAIN |Hello Dr. Corenman,
I find your website to be very informative and helpful. My neighbor mentioned your name after his successful fusion for a severe spondylolisthesis.I am about 5 and half months in from a disk herniation on 1/5/2022. I was playing basketball and felt an injury after a flexion twist maneuver to grab a loose ball. Over the past several months, I have received multiple opinions, some of which have been conflicting.
Initially, I had all the classic symptoms of a herniated disk, difficulties with bending over, etc. My back pain usually felt R sided midline and primarily in the buttocks. Over time, I noticed mainly tingling, pins/needles in my R foot. A few months in, I began to feel these same sensations in my left foot. Worse with sitting. These sensations have come and gone.
I feel like I have improved somewhat, my back and buttock pain is now a 0 or 1. I’m starting to resume some of my activities like hiking. I am riding my bicycle. I’ve received an initial TFESI R sided on L4/L5 and L5/S1. I had a follow up TFESI for diagnostic and therapeutic means on L5/S1. I did receive moderate relief. My main complaint now is bilateral parathesias in my feet, with right being worse than left. Sometimes it is bilateral, sometimes it is unilateral on the R. probably 80/20 R sided. Sometimes my left side does not bother me at all. My feet feel hypersensitive and sometimes I have mild pain.
Imaging has shown a bilateral pars defect (acquired- diagnosed when I was 18- I played HS football. I wore a boston brace for 6 months. I had a fibrotic union.). Imaging has also shown a very mild spondylolithesis at the level below. MRI also showed a broad based disc bulge on L4/L5 and a small R sided extrusion and herniation on L5/S1 likely contacting the S1 nerve root. Both are fairly posterior in nature. EMG/NCS have been negative.
Since my back and glute pain has improved substantially, I am hesitant to consider back surgery. I am 39 years old. Surgeon A has recommended a decompressive laminectomy with foraminotomy for L5-S1. He seems to think I am fusion candidate as well. Surgeon B has recommended a microdiscectomy at L5-S1. Surgeon B thinks I am a fusion candidate in another 10-30 years or when my slippage gets worse. (I do not have pain with extension). I’m on the fence on what to do. I feel I am doing well with conservative treatment and getting some improvements. Neither surgeon is pushing surgery on me. My fear is that the pins/needles in my foot/feet will not get better without surgery. I’ve met with a neurologist who gave me a thorough workup for peripheral neuropathy which was negative. He advised me to give it time to heal. I am generally in good health and a fit and active patient.
I guess this is a 2 part question….
1. Would the Paresthesias improve with surgery?
2. Would you have a preferred surgical approach?Thank you,
Luke
#35112 In reply to: Urod pars repair with bmp |Successful pars repair depends upon how much slip was present before surgery, how much “gap” (or distraction) of the fracture ends was noted prior to surgery, what the quality of the disc was and how precise the repair of the pars defect was performed. At this point, I really can’t tell without images how predictable your pars repair healing will be. If your pain is “really bad”, maybe X-rays with flexion-extension will be helpful and eventually a precise CT scan will 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.#35072 In reply to: Sciatica following L3-4 XLIF?? |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.
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