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Dr. Mark
Dr. Mark, Physician / Surgeon
Category: Medical
Satisfied Customers: 11946
Experience:  U.S. Surgeon / Neurological Surgery
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I have been diagnosed with bilateral pars defect of the L5

Resolved Question:

I have been diagnosed with bilateral pars defect of the L5 vertebrae. I have been to at least 6 different doctors and all point to a lumbar spinal fusion as my best bet for pain relief as many conservative treatments have not been successful. My medical insurance has denied the request for surgery twice saying there is no proof of spondylolisthesis. What do I do now? I have been off work due to the pain since January. Do I file for SSD???
Submitted: 6 years ago.
Category: Medical
Expert:  Dr. Mark replied 6 years ago.
It seems that if all of your doctors have evaluated you and determined that you have instability in your spine (from the pars defect) -- that a fusion surgery would help you.

Unfortunately, it seems that your insurance company does not agree (a nurse reviewer is seeing if your doctor's notes have the key words necessary for approval).

So -- you should discuss this with your surgeon, to see if they can do further studies (such as flexion and extension views) to determine if you have instability in your spine, or to see if your pars defect does cause a listhesis in certain positions.

Of course - a fusion surgery does not guarantee pain relief, so that is why your insurance company wants further proof that a surgery could help. A surgeon could file an appeal with your insurance company asking for a physician reviewer to see if your surgery can be approved.
Customer: replied 6 years ago.

Are the flexion and extension views done by xray? To positively diagnose the pars defect, they did a CT scan and xrays where i had to bend forward and then bend backward (or try to). I have also had an MRI which showed nothing. I also have numbness & tingling down one leg - if i touch my outer thigh, i can feel it in my inner calf. The first denial said that I didn't have enough nerve damage to warrant surgery, but they did no nerve conductivity tests. This new denial basically denied the surgery because there was no proof of spondylolisthesis, but from everything I have read there have been cases of fusion done for the spondylolysis by it possible that even tho I am in constant pain that I have to wait for something more severe to happen for them to approve surgery???



Expert:  Dr. Mark replied 6 years ago.

The bending forward and backward are the flex-ex films.

Right now, you have to understand it from the insurance company's point of view. If you have no spondylolisthesis -- right now, on the MRI, your spinal cord looks essentially normal. The nerves are wide open, and there isn't anything that is putting pressure on your nerves.

So, in their eyes -- there isn't much that can be done for you.

Spondylolysis though, can cause back pain with the instability in the lower back, and often times this is tough to show. But generally many people do have your condition, but without any pain -- and eventually you can develop the spondylolisthesis.

Perhaps you can get an EMG test, which can show if there is any nerve issues This is performed by a neurologist.

Customer: replied 6 years ago.

Outside of surgery, can you suggest any other treatment options? I feel like I need to do something more than just sit around and wait for my condition to progress to a point where I either have more nerve damage or it develops into spondylolisthesis.

Expert:  Dr. Mark replied 6 years ago.
Well, really the only permanent thing you can do is to aggressively strengthen your core back muscles.

Strengthening your back muscles helps to "stabilize" your lower back, and lessens the pain from a spondylolysis.

This is called core muscle strengthening -- and you really have to get these muscles stronger for any benefit. Physical therapy to show you these exercises would be helpful.

The other things -- steroid injections, pain medications, a brace - only help to "mask" the true issue, and really would be only temporary fixes to your issue.
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