Join Date: Dec 2002
Location: Concord, CA, USA
I think this article I am going to post will be VERY helpful to your cousin's husband.
Failed Back Surgery Syndrome: What it is and how to avoid it
Failed back surgery syndrome (also called FBSS, or failed back syndrome) is a misnomer, as it is not actually a syndrome - it is a very generalized term that is often used to describe the condition of patients who have not had a successful result with spine surgery. There is no equivalent term for this in any other type of surgery (e.g. there is no failed cardiac surgery syndrome, failed knee surgery syndrome, etc).
There are many reasons that a surgery may or may not work, and even with the best surgeon and for the best indications, spine surgery is no more than 95% predictive of a successful result.
Spine surgery is only basically able to accomplish two things:
1) Decompressing a nerve root that is pinched, or
2) Stabilizing a painful joint
Unfortunately, surgery cannot literally cut out a patientís pain. It is only able to change anatomy, and an anatomical lesion (injury) that is a probable cause of pain must be identified prior to surgery.
By far the number one reason surgery is not effective is because the lesion that was operated on is not in fact the cause of the patientís pain. In most cases of lower back pain, a pain generator cannot be found and surgery is very unpredictable. For this reason, accurate preoperative patient selection is critical to a successful surgical outcome.
Some types of surgery are far more predictable in terms of alleviating a patientís symptoms than others. For instance,
∑ A discectomy (or microdiscectomy) for a lumbar disc herniation that is causing leg pain is a very predictable operation. However, a discectomy for a lumbar disc herniation that is causing lower back pain is far less likely to be successful.
∑ A spine fusion for spinal instability (e.g. spondylolisthesis) is a relatively predictable operation. However, a spine fusion for multi-level lumbar degenerative disc disease is far less likely to be successful in reducing a patientís pain.
Therefore, the best way to avoid a spine surgery that leads to an unsuccessful result is to stick to operations that have a high degree of success and to make sure that an anatomic lesion that is amenable to surgical correction is identified preoperatively.
In addition to the above-mentioned cause of failed back surgery syndrome, there are several other potential causes of a failed surgery, or continued pain after surgery:
∑ Fusion surgery considerations (such as failure to fuse and/or implant failure, or a transfer lesion to another level after a spine fusion, when the next level degenerates and becomes a pain generator)
∑ Lumbar decompression surgery considerations (such as recurrent stenosis or disc herniation, inadequate decompression of a nerve root, preoperative nerve damage that does not heal after a decompressive surgery, or nerve damage that occurs during the surgery)
∑ Scar tissue considerations
∑ Postoperative rehabilitation (continued pain from a secondary pain generator)
Fusion surgery considerations
In addition to the primary reasons for failed fusion surgery discussed on the prior page, there are several reasons why a fusion surgery might fail to alleviate a patientís pain.
Failure to fuse
When the fusion operation is for back pain and/or spinal instability, there is a correlation (although weak) between obtaining a solid fusion and having a better result. If a solid fusion is not obtained, but the hardware is intact and there is still good stability to the spine, the patient may still have good pain relief with the surgery. In many cases, achieving spinal stability alone is more important than obtaining a solid fusion.
On postoperative imaging studies it is often very difficult to tell if a patientís spine has fused, and it can be even harder to determine if a further fusion surgery is necessary. In general, it takes at least three months to get a solid fusion, and it can take up to a year. For this reason, most surgeons will not consider further surgery if the healing time has been less than one year. Only in cases where there has been breakage of the hardware and there is obvious failure of the spinal construct would surgery be considered sooner.
An instrumented fusion can fail if there is not enough support to hold the spine while it is fusing. Therefore, spinal hardware (e.g. pedicle screws) may be used as an internal splint to hold the spine while it fuses. However, like any other metal it can fatigue and break (sort of like when one bends a paper clip repeatedly). In very unstable spines, it is therefore a race between the spine fusing (and the patientís bone then providing support for the spine), and the metal failing.
Metal failure (also called hardware failure, implant failure), especially early in the postoperative course, is an indicator of continued gross spinal instability. The larger a patient is and the more segments that are fused, the higher the likelihood of implant failure. Implant failure should be very uncommon in normal sized individuals with a one level fusion.
Transfer lesion to another level after a spine fusion
A patient may experience recurrent pain many years after a fusion surgery. This can happen because the level above a segment that has been successfully fused can breakdown and become a pain generator.
∑ This degeneration is most likely to happen after a two-level fusion (e.g. a fusion for L4-L5 and L5-S1 levels) and in a young patient (in the 30-50 year old age range).
∑ It is much less likely to happen if only the L5-S1 level is fused, as this segment typically does not have much motion and fusing this level does not change the mechanics in the spine all that much.
∑ Most of the motion in the spine is at the L4-L5 level, and to a lesser extent at L3-L4. When the L4-L5 level is included in the spine fusion it transfers a lot of stress to L3-L4. This does not present as much of a problem for elderly patients, since they tend to not be as active nor do they have the fusion for as many years.
Lumbar decompression surgery considerations
For a lumbar decompression (a discectomy, microdiscectomy or laminectomy), it can take a long time for the nerve root to heal. In general, if a patient is getting better within three months following the surgery, he or she should continue to get better. If there has not been any improvement within three months, then the surgery can be assumed to be unsuccessful, and further work up would be reasonable. Within the first three months the success of the surgery really cannot be judged.
Lumbar decompression surgery will usually relieve the patientís leg pain directly after surgery. However, for 10-20% of patients the pain will continue until the nerve starts to heal. In some cases, the pain may even be worse for a while because operating around the nerve root creates some increased swelling and this leads to pain.
Recurrent stenosis or disc herniation
Years after a decompression surgery (lumbar laminectomy), the stenosis can come back (the bone can grow back) at the same level, or a new level can become stenotic and cause pain and/or other symptoms.
Pain that is relieved right after surgery but then returns abruptly is often due to a recurrent lumbar disc herniation. Recurrent lumbar disc herniations happen to about 5% to 10% of patients, and they are most likely to occur during the first three months after the surgery.
Three potential technical problems that can cause pain to continue after surgery include:
∑ Missed fragment (of the disc or bone) is still pinching the nerve
∑ The operation was done at the wrong level of the spine.
∑ Nerve damage or injury during the course of the operation
Nerve damage during a discectomy or a lumbar decompression is very uncommon, but has been reported in about 1 in 1,000 cases. When it does occur, a permanent neurological deficit with new weakness in a muscle group is possible, and a postoperative EMG (electromyography) can be helpful to see if there has been nerve damage and if there is any reinnervation (nerve healing).
All of these technical problems should be very uncommon. If any of these issues are suspected, a repeat MRI scan may be helpful.
At times, decompressing a nerve root will cause it to become more inflamed and lead to more pain temporarily until the inflammation subsides. In the initial postoperative period, oral steroids and occasionally other medications (e.g. Neurotin) can help diminish the pain from this inflammation until it gets better.
Inadequate decompression of a nerve root
Surgery to decompress a nerve root is not always successful, and if a portion of the nerve root is still pinched after the surgery there can be continued pain. If this is the case, there will usually be no initial pain relief following the surgery, and subsequent postoperative imaging studies may show continued stenosis in a portion of the spine.
Scar tissue and continued pain after surgery
Scar tissue formation is part of the normal healing process after a surgical intervention. While scar tissue can be a cause of pain, in and of itself it is rarely painful, since the tissue contains no nerve endings. Rather, the principal mechanism of pain is thought to be the binding of the lumbar nerve root by fibrous adhesions, called epidural fibrosis.
These fibrous adhesions are a common occurrence after spine surgery, and occur for patients with successful surgical outcomes as well as for patients with continued or recurrent leg pain and back pain. For this reason, the importance of scar tissue or epidural fibrosis as a potential cause of continued pain after surgery is controversial.
One common occurrence is when a patient still has pain postoperatively and the only remarkable finding on a new MRI scan is that there is now scar tissue. It may therefore be assumed that the scar tissue is now causing the patientís pain. However, if the patientís pain feels the same as it did preoperatively (and there was no scar tissue at that time) why is it now assumed be the cause of the patientís symptoms? It is far more reasonable to assume that the original cause of the patientís pain was not addressed by the surgery.
The one time that scar tissue (epidural fibrosis) may be symptomatic is for a patient who initially does well after a discectomy or a decompression, only to have recurrent pain come on slowly between 6 to 12 weeks after surgery. This is the time period that scar tissue takes to form.
Pain that starts years after surgery, or pain that continues after surgery and is never relieved, is not from scar tissue.
After an incorrect preoperative diagnosis, probably the second most common cause of failed back surgery is improper and/or inadequate postoperative rehabilitation. As stated earlier, it often takes months to a year to heal after many of these surgeries, and a postoperative rehabilitation program that includes stretching, strengthening and conditioning is an important part of any successful surgery.
In general, the bigger the surgery, and the longer a patient has had their preoperative symptoms, the longer and harder the postoperative rehabilitation will be. It is often far more reasonable to continue with rehabilitation after surgery than to consider further surgery (with some exceptions, such as if there has been a recurrent disc herniation).
Often, there are other secondary problems that must be worked out after surgery. For example, a patient with a pinched L5 nerve root from a disc herniation may still need physical therapy afterward because they may have a secondary piriformis syndrome. Unpinching the L5 nerve root may relieve the radiculopathy (sciatica) but the patient still has pain in the buttocks from continued muscle spasm in the piriformis. Until this is worked out the patient will not feel like the surgery is successful.
Many times, spine surgery is necessary to provide enough pain relief for the patient to start a rehabilitation program, but it should only be one component of the patientís healing process.
Unfortunately, some patients feel that if they have had surgery they have been ďfixedĒ and no further treatment is necessary. However, this is rarely true, and continued therapies and rehabilitation are usually necessary for a successful outcome.
After surgery, careful follow-up and rehabilitation is very important. If there is continued pain after surgery, despite adequate time to heal and rehabilitation, then further workup may be warranted to find if there is a new lesion or a different type of problem that could contribute to the patientís pain.
Failed back surgery syndrome is really not a syndrome, and there are no typical scenarios. Every patient is different, and a patientís continued treatment and workup need to be individualized to his or her particular problem and situation.
By: Peter F. Ullrich, Jr., MD
January 28, 2003
If this doesn't help, let me know...I have bunches and bunches of articles and stuff, maybe I chose the wrong one...?? Good luck to your cousin's hubby.
Oct 2000: Repetitive Stress Injury-Inverted Hernia
Feb 2001: MRI. Shows only slight bulge at L4-L5
Dec 2001: Discogram/CT scan shows Inverted Hernia at L5-S1. L4-L5 & L5-S1 ruptured in all 4 quadrants. Unable to walk.
Feb 2002: IDET, Nucleoplasty, Intra-Discal Injections
Sept 2002: Rated in the top 10% for successful patients. Retraining for new career.