Lollipop

Hello Dr. Corenman,
I saw my ortho surgeon this morning. He said he wouldn’t do a TLIF at L4-5 due to the scar tissue present and increased possible nerve damage with that procedure. I have had a L4-5 decompression with partial discectomy in 2012 and had the rod and pedicle screw fusion one year ago, so I do understand the increased risk of damaging nerves. This would be the third surgery there in four years. He said he would use BMP and place a larger screw at Left L4, leaving the other screws in place if the look good.
He said he would do rod and pedicle screws at L3-4… I THINK because of the loss of disc height and foraminal narrowing… He said he would do a TLIF at L5-S1 as there is no disc space and some of my symptoms are indicative of that.
What are your thoughts, and do ALL pseudarthroses require a revision? Thank you again, as always!

Hi Dr. Corenman,
I got my MRI results from August 31. I spoke with my doc on the phone regarding the results. I have an appt. with him next week. I wonder if you could read the results of my recent CT scan listed above along with my MRI results and tell me what you think. I MISTAKINGLY put there is hardware failure on the CT result, there IS NOT.
My doc says the Left L4 screw is very loose and basically moving like a wind shield wiper. Here is the plan I understood while taking notes from phone conversation.
L5-S1 a TLIF
L4-5 harvest bone from iliac crest to graft here and place a larger screw.
L3-4 do a fusion with rods and pedicle screws
It is possible I didn’t get everything right and am going to clarify with him next week.

Clinical information: Chronic pain since March. History of spinal surgery. Unenhanced T1 and T2 MR images of the lumbar spine were obtained. Comparison is made with 5/27/2015 CT. Bilateral pedicle screw/rod fusion has been performed at L4-5 since the previous exam.
There is approximately 1 cm anterior subluxation of L4 relative to L5 slightly greater than noted on the prior exam. Laminectomy has been performed at this level with posterior bulging of the thecal sac into the laminectomy defect.
L5-S1: There is 1 to 2 mm retrolisthesis of L5 with mild broad disc bulge and endplate spurring mildly narrowing the neural foramina bilaterally.
L4-5: Neural foramina are narrowed secondary to the spondylolisthesis on the left and associated disc bulge with slight narrowing on the right. There is near complete loss of disc height.
L3-4: The neural foramina are narrowed more so on the right by disc bulge and endplate spurring with mild lateral recess stenosis as well. There is loss of disc height and signal intensity.
L2-3: The lateral recesses are mildly narrowed by disc bulge and facet and ligament hypertrophy with mild narrowing of the foramina as well. There is loss of disc height and signal intensity
. L1-2: No canal or foraminal stenosis is noted. The disc has slight degenerative loss of signal intensity.
T12-L1 and T11-12: No disc protrusions noted. The spinal cord tip ends normally at T12.
IMPRESSION: 1. Postoperative changes are present as noted. 2. The left L4-5 foramen is narrowed secondary to the spondylolisthesis and disc bulge. 3. Foraminal stenoses are present bilaterally at L3-4 more so on the right

I have chronic burning low back and nerve pain along L4-S1 dermatomes that comes and goes, tingling middle three toes left foot and stinging in low back left greater than right. Pain with turning at night. Today burning low back is about a 7/10. What are your thoughts based on CT and MRI results? Thank you very much!

Hi Dr. Corenman,
So I had the CT scan and I do have hardware failure. Here are the results of the CT of 8/11/16

T12-L2 The disc space is maintained.

L2-L3 There is moderate to marked narrowing of the disc interspace with a mild 1.51 m retrolisthesis and mild posterior osteophytic lipping-disc complex extending foraminally greater on the right by approximately 3mm. There is mild hypertrophy of the posterior elements, and these factors result in a mild canal stenosis and mild right and mild-to-moderate left foraminal impingment.

L3-L4 There is mild to moderate disc space narrowing with posterior osteophytic lipping-disc complex x 3mm. There is moderate hypertrophy at the apophyseal joints, probably due to a combination of degenerative change and perhaps some bone graft and fusion from surgery described below.

L4-L5 There has been L4 and L5 laminectomies, transfixed with posterior rods and transpedicular L4-L5 screws. There is evidence of hardware failure. A grade 2 spondylolisthesis is present at the L4-L5 level with moderate to marked narrowing of the disc interspace and sclerosis left laterally. There are pars and articularis defects more conspicuous on the left with diastases x 6 mm, again apparently transfixed with posterior rods. There is also hypertrophy at the apophyseal joints again probably from degenerative change and bone fusion.

L5-S1 Moderate to marked narrowing of the disc interspace with packing phenomena anteriorly with moderate anterior right lateral endplate sclerosis and osteopytic lipping. Osteophytic lipping form the inferior L5 endplate at the neural foramina and mild apophyseal hypertrophy results in mild right and moderate left foraminal impingement.

The remaining bony structures remain intact.
Other findings: None significant

Impression: Postsurgical changes as described, with transfixation of a grade 2 L4-L5 spondylolisthesis and spondylolysis. Moderate degenerative change as described including mild canal stenosis and foraminal impingement greater on the left at the L2-3 level, and foraminal impingement at the L5-S1 level greater on the left.

My doc says if I want to do anything he would remove current hardware and put in larger screws with possible fusion of L3-4, L5-S1. He would order an MRI before proceeding further. Is this something I can wait out and see what happens or do you think I should get the MRI to see the “soft” tissue involvement? I can live with things as they are but I am concerned that it will only get worse and cause permanent nerve damage.

I have quite a history with my spine and it is getting very frustrating. I have listed my PMH in previous emails to you. I’m 58, female, 135 pounds, 5’2″, non smoker and active walker and strength trainer. I do have osteoporosis and have had Reclast infusions as listed previously.
I am overwhelmed…. The fusion failed, further fusions could too. What are your thoughts? Thanks AGAIN!