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  • Donald Corenman, MD, DC
    Moderator
    Post count: 8660

    Your surgeon notes that the slip has slightly increased and “there is no obvious consolidation in the lateral gutters” which probably means that the fusion is not progressing as intended. The lack of fusion and the increased slip might indicate foraminal stenosis which would explain the significant leg pain.

    With the intensity of your current symptoms, you might ask this physician if she might order a CT scan or an MRI. The CT scan will determine what the current state of your fusion is along with denoting foraminal stenosis. The MRI would not help with fusion status but would delineate the state of compression of the nerve root.

    If that plan does not work, you could consider a second opinion.

    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.
    leo42ray
    Member
    Post count: 3
    #7506
    Topic: Dura Deficeincy in forum GENERAL |

    What could a person expect in the way of symptoms in the event of a long term dura deficency? Say 7 months or more. I had a spinal fusion surgery in 1997 (11 vertebrae 6 discs). Ten years later had some minor events occur. Found rods broken in the thoracic region. After an auto accident started suffering major muscle spasms & weakness, trunk to both legs numbness, falling down as well as other issues. MRI and CT scans showed normal. Only thing obvious was where the rods broke. Surgon decided he would repair the spot where the rods were broken. During the operation he discoverd the dura in fact was gone. He removed the vertebra to get where the dura was missing and placed a patch over it and reinstalled vertabrae using bone grafts and new hardware. I am now having MS symptoms with MRI of brain showing few hypointensities (very small)no white matter. EMG normal. Neurologist gave up after that and told me to go to the Mayo Clinic. Perscribed 6 months of physical theapy. Therapist (who works with a lot of MS patients took one look atme and I should be on disability becase I had MS. Help!!!!!!!!!!!!!

    ziotech
    Member
    Post count: 1
    #7494
    Topic: Need a diagnosis in forum BACK PAIN |

    History:
    I had bent slightly while picking up a computer and suddenly felt a shooting pain originating in my lower right back and moving up the right side of my spine. This occurred over 4 years ago. The MRI at the time revealed a disc bulge at L4-5 with a superimposed left foraminal annular tear and fluid in the facet joints bilaterally.
    At L5-S1 there is a disc bulge with a superimposed central posterior disc herniation with indentation of the ventral margin of the thecal sac.

    For several years after the initial injury the pain was minor and tolerable as long as I stayed within reasonable limits of activity. It has increased over the past year and now that I am in a prescribed core exercise therapy routine it has gotten much worse. My primary physician can not explain why this is so.
    My most recent MRI (March of 2012) was unrevealing according to him.

    Location:
    Primary pain is located in the lower right back area and begins to extend first downward into the right buttock and thigh, then upward just to the right of the spine after extended upright sitting or increased physical activity.

    Percentage of pain is 70/30 on average.

    Quality and Intensity:
    The quality is a constant ache with movement at level 2 on the VAS (10 months ago). This is the pain level with minimal activity. During increased activity such as core exercise therapy (Current) this pain level rises to a constant 3-5 and becomes more of a stabbing type of strong discomfort and a cramping type of pain occurs in the upper part of the right buttock as well. Then there is a crippling failure (crises) at level 9 (Crippling failure happened on Oct. 30th after crouching and has happened approx every 2 months before that for the past year) after increased activity which occurs after bending, lifting, kneeling or crouching following the 3-5 VAS pain level.
    Skin at the location is hypersensitive to touch and heat.

    Weakness:
    There is some weakness associated with the condition and exists in the right leg. Climbing stairs and extended walking are negatively effected. There is a pronounced limp after increased activity or sitting upright for extended periods.

    Activities:
    The most painful are lifting, bending (both shallow and deep), kneeling and crouching. Sitting upright in a standard type of moderately padded office chair begins to become difficult after 1 hour and pain spreads down the right leg and up the right spine. Intolerable at the 2 hour mark. Reclining in a more padded chair provides some relief. Standing also temporarily reduces the pain from sitting upright provided that I favor my left side. Standing becomes difficult after 2 hours due to increased back and leg pain.
    Walking is limited to 1/2 mile before rest is required. Pain increases over time while standing, walking or sitting upright. Pain increases sharply with repeated kneeling, bending, twisting, lifting or crouching. Jumping and running are out of the question. Both of these activities cause extreme pain instantly. Biking on an actual mobile bicycle is out of the question due to impact issues but stationary biking is tolerable for up to 1/2 hour.
    There is instability pain as described above, after increased activity and increased pain levels leading to crises mode which cripples me for weeks.
    Daily function varies with activity and pain levels. I try to greatly limit my bending, crouching and anything described above that causes sharp increases in pain levels.

    Occupational restrictions:
    I was effectively released from my position due to these back issues and they have made it impossible for me to keep a job. At any moment I can suffer crippling back failure and can barely stand, walk or sit. I was an IT consultant which required me to move a lot of equipment weighing up to 50 lbs. Now any repeated lifting, bending, twisting, kneeling or crouching is out of the question. After inactivity and healing over the course of months I can lift a 40Lb object and move it 100 ft once with tolerable discomfort but not repeatedly. Since I can not sit upright for any length of time or stand for very long this leaves me in a permanently disabled and effectively unemployable state.

    Treatment:
    Initial physical therapy failed and caused more pain. Secondary therapy was slightly better. Now enduring a 3rd round of therapy that is proving largely unsuccessful. My primary physician claims that core exercises and medication will alleviate the condition. He is incorrect. Core exercises may strengthen the surrounding muscles but cause the actual injury to weaken and fail at crises levels. Currently in low impact hydrotherapy which helps the muscles become stronger but also increases the pain and discomfort in the injured area.
    Years ago a spine specialist told me that I was not a good candidate for surgery and that I would have to live with the discomfort and would probably never work again. At that time I thought I could continue to heal and be capable of most of the things I did before the injury. Now I know that is not going to happen.

    Here’s the immediate issue….My primary physician tells me that I should not be experiencing the problems I am experiencing based on my latest MRI. He continues to prescribe medication and core exercise therapy and admits he has no idea why I would be in so much pain. I need to know what is going on here and why I keep experiencing crippling back trauma over and over again. Why the exercise therapy seems to be aggravating the injury instead of strengthening and stabilizing the area. Any insight you may have would be most appreciated.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8660

    My issue is, I have to trust the MRI images implicitly to be absolutely accurate in performing surgery. The good news is that these images have to correspond with the history and physical examination and if they don’t make sense, I can have other tests performed to confirm the findings. There are times the Fonar images can be used for surgical planning but I have seen times that a more precise scan is necessary.

    The only time that I think an MRI scan needs to include motion images is in the rare case of a hydraulic disc causing radiculopathy. This is a disc that bulges posteriorly with load and the bulge reduces with unloading. Flexion/extension X-rays will not diagnose this disorder. However, this type of disc can be diagnosed with a discogram. I see this type of disc about once every two years so ordering a motion MRI for every radiculopathy case would not be cost effective as the necessity for possible repeat scanning.

    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.
    Donald Corenman, MD, DC
    Moderator
    Post count: 8660

    The change in your disc appearance over time most likely indicates a non-solid fusion. Flexion/extension x-rays do not have to demonstrate gross motion for a non-union to be present but there are subtle signs that can indicate motion without measurable motion being present.

    See if you can ask your current doctor for a CT scan of the L5-S1 segment. The scan should be on a 64 slice or 128 slice scanner for the best accuracy.

    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.
    Seattle Scott
    Member
    Post count: 5
    #7450 In reply to: Direct Pars Repair |

    Yes, I reviewed the information on your site, which led me to post on your forum.

    I did have a lido infiltration of my pars, which yielded some relief. However, during the procedure you could see that the injection went in 1 side of the pars and then came right out the other side into the surrounding structures. So, according to the dr., he could not be sure the success could be attributed to the pars.

    Here is the summary from the MRI about the discs. I guess healthy is relative.

    FINDINGS: No evidence of vertebral compression or destructive lesion. No evidence of subluxation. Bilateral L5 pars defects are again noted. Visible caudal spinal cord is normal caliber and signal. Conus terminates in normal location at T12-L1.
    T10-T11: Normal disc hydration and stature. No disc bulge, protrusion, or extrusion. No central canal or neural foraminal stenosis.
    T11-T12: Normal disc hydration and stature. T12 superior end plate Schmorl’s node, unchanged. No disc bulge, protrusion, or extrusion. No central canal or neural foraminal stenosis.
    T12-L1: Normal disc hydration and stature. No disc bulge, protrusion, or extrusion. No central canal or neural foraminal stenosis.
    L1-L2: Moderate disc desiccation and moderately diminished disc stature. L1 inferior and L2 superior end plate Schmorl’s nodes, unchanged. Shallow disc bulge causes no central canal or neural foraminal stenosis. No focal protrusion or extrusion.
    L2-L3: Mild disc desiccation with normal stature. L2 inferior endplate Schmorl’s node, unchanged. No disc bulge, protrusion or extrusion. No central canal or neural foraminal stenosis. No interval change.
    L3-L4: Mild disc desiccation and mildly diminished disc stature. Shallow diffuse disc bulge is unchanged. No central canal or neural foraminal stenosis.
    L4-L5: Moderate disc desiccation and moderately diminished disc stature. Focal central protrusion with high intensity zone (annular fissure) indents the ventral thecal sac but causes no central canal stenosis. Mild bilateral facet joint arthrosis causes no neural foraminal stenosis. No interval change appreciated.
    L5-S1: Normal disc hydration and stature. No disc bulge, protrusion, or extrusion. No central canal stenosis. Stable mild bilateral facet joint arthrosis but no neural foraminal stenosis.
    IMPRESSION:
    1. Bilateral L5 pars defects and mild bilateral facet joint arthrosis, unchanged.
    2. L4-L5 focal central protrusion with high intensity zone (annular fissure) and mild bilateral facet joint arthrosis without central canal or neural foraminal stenosis, unchanged.
    3. L3-L4 shallow diffuse disc bulge without central canal or neural foraminal stenosis, unchanged.
    5. L1-L2 shallow disc bulge without central canal or neural foraminal stenosis, unchanged.

    I’m not sure if this would make me suitable for a potential pars repair v. a fusion. My concern with fusion, is that while I do have leg pain, it’s not so bad. For me, its more the lack of stability and that I can no longer exercise, ski, bike, run, etc. I would only consider surgery, if there was a good shot of returning to those activities. While I do have pain and some sleep disturbance, it’s not so awful that I cannot tolerate it.

    Thanks again for the discussion. I appreciate you cannot give medical advice via the Internet.

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