What Are We Seeing In This Image
Spinal instability at the L3-L4 segment above a previous L5-S1 fusion.
- In the first of the three panels starting at the left, we see the patient in the NEUTRAL, standing straight position. In this position, we see the L3 has slipped well forward above the L4 vertebrae. We also see space between the Neuroforamina.
- In the center of the three panels, we see the FLEXION position. The patient is bending forward. We also see space between the Neuroforamina.
- The third panel is an image of the spine in EXTENSION. This would be a position not only of bending backward but a position many athletes, tennis, golf, running or sports or work with overhead arm motion required. In this position, there is a narrowing of the space between the Neuroforamina. This can cause Lumbar Radiculopathy or lumbar stenosis situation.
In patients we see, Prolotherapy injections would be recommended for appropriate candidates where a realistic expectation of 90% pain relief may be achieved. This is not attainable in all patients and is not typical. But for appropriate candidates, significant pain relief can be achieved.
The Migration Of An Implant
FBSS can also occur when an implant migrates to another location. Occasionally, an implant can migrate after its been placed in surgery. Most often, this will occur during the recovery stage well before the patients body has healed enough to allow the implant to fully attach to the intended vertebrae.
An ineffective or shifted implant can affect the bodys neural tissue, causing additional pain.
Enhancing Healthcare Team Outcomes
interprofessional pain clinics are the gold standard in the setting of treatment for patients with complex chronic pain syndromes such as failed back surgery syndrome. The interprofessional care team in these clinics consists of pain physicians, nurses, psychologists, psychiatrists, physical therapists, pharmacists, and occupational therapists. The integration of different members of the healthcare team results in close communication between experts in distinct methodologies of treating chronic pain and promotes a biopsychosocial approach to the patients pain.
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How Does Failed Back Surgery Syndrome Occur
The back surgery focuses on accomplishing two objectives treat a painful joint or release a squeezed nerve root. However, these two objectives achieved through anatomical changes often fail to address pain symptoms effectively. Scar tissue development following the surgical intervention and inability of the surgery to make adequate changes due to delicate spinal structure play a role in causing pain new conditions and continuation of the existing pain. Intervention also irritates nerve and damage tissues that help to build up new painful symptoms.
Believe That The Procedure Is Done Too Frequently With Improper Indications And With An Astounding Lack Of Appreciation Of Its Effect On The Mechanical Function Of The Spine
The above is a powerful statement. It was made forty years ago by two leading spinal surgeons Dr. Augustus A. White III and Dr. Manohar M. Panjabi, in their learning and teaching textbook Clinical Biomechanics of the Spine. In this publication, they stated simply: We believe that the procedure is done too frequently with improper indications, and with an astounding lack of appreciation of its effect on the mechanical function of the spine.
Over 40 years later, little has changed.
All spinal surgeries alter spinal mechanics, causing more force to be generated at the areas surrounding the spinal surgical site.
- In spinal laminectomies and microdiscectomies, the surgical procedure may contribute to clinical instability through the removal of supporting structures of the spinal column. This will alter the spinal dynamic and make the patient more susceptible to new pain.
- With spinal fusions, pain can be felt at the non-fused adjacent segments. The parts of the spine immediately above and below the surgery site.
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Causes Of Chronic Post
Before we look at the latest findings on how to help patients understand their failed back surgery and what they can do about it, lets have Ross Hauser, MD present a brief summary introduction.
In this video, Ross Hauser, MD describes the 5 main reasons that back surgery failed to help the patients condition.
Generally speaking, spinal pain that occurs right after surgery is from sensitized nerves, while chronic post-surgical spinal pain is often from spinal instability, but, can have many different causes. Some of these problems can include:
Now lets get to the research:
Treatment For Failed Back Surgery Syndrome
Orthopaedic spine surgeon Ralph Rashbaum, MD continues his discussion about failed back surgery syndrome . In this segment, Dr. Rashbaum explains his approach to proper patient care when back surgery is not successful.
“Physicians from the family practitioner on up to the sophisticated spine surgeon need to recognize that surgery is not he be-all and end-all.” Photo Source: 123RF.com.
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Depression After Failed Back Surgery
In the May 2017 edition of the Journal of Physical Therapy Science, researchers concluded that the surgery experience in patients with ongoing low-back pain makes their pain and depression worse.
Here are the learning points from this research:
Doctors have long been aware that many patients experience some form of post-surgical depression in the six months following an invasive procedure. However, some researchers believe that being depressed after surgery is understandable and unworthy of diagnosis or treatment.
As most people with post-surgical depression emerge from depression after about six months, many doctors consider post-surgical depression either benign or even helpful as it keeps people inactive. Nevertheless, researchers have discovered that depressed patients are more likely to have other complications following back surgery.
They are less able to cooperate in their after-care, particularly in rehabilitative therapy. For people who have an existing history of depression and anxiety, recovery from post-surgical depression is neither guaranteed nor as straightforward as some surgeons expected.
Please see a further discussion at our article Chronic back pain the impact of depression and anxiety
When A Patient Comes To You And Their Surgery Was Not Successful What Do You Do
Dr. Rashbaum: We find out what went wrong. Typically, the patients I see that clearly have failed back surgery syndrome go back to their doctor, only to find that their doctors are totally disengaged in finding the truth. Unfortunately, this is common.
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Im sorry, Ive done everything I can I did it the right way, by implication theyre alleging they didnt commit malpractice, and, frankly, most of them havent.
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I cant help you, youll have to go someplace else, doesnt help the situation. They dont arrange for the someplace else, and basically what happens is these people become a referral base or repository in chronic pain syndrome in a pain doctors clinic.
One of the biggest concerns pertains to whether or not the patient is being subjected to a robust reassessment by the operating surgeon. Id like to think that they were, but theyre not at least not uniformly. Theyre just sending these people down the road, where the problem could easily be assessed by repeating diagnostic studies like an MRI with gadolinium an enhancer that helps us ferret out scar tissue from a recurrent disc herniation. You cant get anywhere if you operate on somebody with scar tissue for leg pain, but you certainly can if they have a recurrent disc herniation.
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When The Surgery Itself Causes New Post
When you fuse two or three spinal segments together, mobility is lost. Spinal twisting and torque movement, however, have to come from somewhere. Where? The spinal segments above and below the fusion. These vertebral segments now have to move excessively to compensate. Ultimately, this extra movement and strain will cause accelerated degeneration of the disc, ligaments, and joints of these segments, thus making the person more prone to pain in these areas. This is most likely the explanation for the increased pain a few years down the road and the need for more operations later.
In research from Harold Wilkinson MD, published in the medical journal Pain Physician,, Dr. Wilkinson looked at difficult back pain cases: Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery, to see is simple dextrose Prolotherapy would be of benefit.
Here are some learning points:
Other Prolotherapy research has shown Prolotherapy can stabilize the areas that are painful. For most cases, three to eight visits of Prolotherapy, given once per month is all that is needed. Remember getting one spinal fusion operation may end up leading to another. Perhaps, a second opinion by a Prolotherapy doctor before getting a spinal fusion operation is needed? It may help you avoid surgery. Please refer to for more discussion Cervical pain Adjacent segment disease following neck surgery.
Why Did My Back Surgery Fail
Although the name of the condition implies your back surgery was a failure, this is not altogether accurate, because some patients do not improve even with the best surgical interventions and careful diagnoses. The goal of any spine surgery is either to decompress a pinched nerve root or to stabilize a painful joint, but unfortunately, no surgery can literally cut out a patients back pain. One of the most common reasons back surgeries fail is because the area the surgeon operated on was not the only cause of their pain. Spine surgery is always a last resort to treat back pain, simply because of the risks of FBSS.
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Failed Back Surgery Syndrome: A Narrative Review
JoãoBatista Santos Garcia1, José Osvaldo Barbosa Neto1*, ÉricaBrandão de Moraes2
1ExperimentalLaboratory to the Study of Pain, Federal University of Maranhão, Brazil
2Aurora de Afonso Costa School ofNursing, Federal Fluminense University, Brazil
*Correspondingauthor: José Osvaldo Barbosa Neto, ExperimentalLaboratory to the Study of Pain, Federal University of Maranhão, Ruados Canários, n1. Apto 1002. Calhau. São Luis, Maranhão, 65071393, Brazil.Tel: +55-98991675217 Email:
ReceivedDate: 06 July, 2019 AcceptedDate: 27August, 2019 02September, 2019
Citation: Garcia JBS, Neto JOB, de Moraes EB Failed Back Surgery Syndrome: A Narrative Review. Chron Pain Manag 2: 116. DOI: 10.29011/2576-957X/100016
Abstract
Background: The prevalence of low back pain varies from 60-80%worldwide, which makes it one of the most common health problems. Spinalsurgery is often indicated as treatment for low back pain, and, even though itis successful in at least 50% of cases, 10-40% of these patients develop FailedBack Surgery Syndrome , presenting with a resurgence of symptoms ordevelopment of complications associated with the intervention.
Objective: The objective of this narrative review is to presentcurrent literature on FBSS and on strategies to prevent or treat the syndrome.
In the face of the challenge of treating patients withfailed back surgery, we should consider the exhausting conservative andminimally invasive treatment before indicating to surgery.
1. Introduction
3. Review
Failed Back Surgery Syndrome Treatment: Intrathecal Drug Delivery
Similar to a spinal cord stimulator, spinal drug delivery involves implanting a small pump in the stomach and running a catheter to the spine to deliver pain medication. It is used for people with chronic back pain who need large doses of narcotics to deal with the pain. Compared to oral medication, this pain pump requires a smaller dose of narcotics because the medication goes directly to the area of pain.
Research in the medical journal Neuromodulation wrote of the benefits of intrathecal drug delivery. Researchers looked at patients who were averaged 67 years of age, was 68% women, and 77% were Medicare beneficiaries.
- Ninety-five percent of patients had low back pain, and 86% had limb pain.
- The majority had pain for more than 5 years.
- Failed treatments included:
- and facet joint injections ,
- with 84% also reporting significant systemic opioid side-effects.
All patients taking long-acting opioids discontinued these within one month of the implant. Total systemic opioid elimination was accomplished by 68% of patients at one-month post-implant, 84% at one year, and 92% at five years.
However, doctors in Germany noted in the journal Pain Physician that the assessment of the functionality of intrathecaldrug delivery systems remains difficult and time-consuming. Catheter-related problems are still very common, and sometimes difficult to diagnose.
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What Happens If My Spinal Fusion Failed
A percentage of patients may still experience pain after a spinal fusion. This is known as failed fusion syndrome. It is characterized by intractable pain and an inability for the patient to return to normal activities. The patient may undergo another surgery to fix the condition. However, the surgery may not eliminate the pain.
Psychological Screening For Surgery
Thus, it is clear that psychological screening is a critical component of the pre-surgical evaluation process. A psychological screening for surgery helps the physician and patient prevent FBSS. Psychosocial factors have been shown to affect surgery outcome. Though physicians are sometimes aware of blatant chemical dependency, psychopathology, or secondary gain issues in their patients, they often miss the less obvious psychosocial problems that may make the difference between a successful and unsuccessful surgery outcome.²² Consideration of psychological factors in concert with physical factors, such as characteristics of the herniation and duration of illness, lead to the most accurate predictions about those patients who will benefit from surgery and those who will not. A psychological evaluation allows the surgeon/physician to improve treatment outcomes by screening out patients likely to have a poor outcome and providing necessary psychological/ emotional assistance prior to surgery, if needed. An evaluation also identifies those patients who are likely to experience medication addiction or compliance difficulties, and who may end up being problem patients for the treating physician.
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Back Surgery Is An Important Treatment Option Yet A Significant Percentage Have A Poor Outcome And May Require Either Additional Surgery Interdisciplinary Treatment Or Implantable Devices To Manage Ensuing Pain
Gatchel R, Miller B, Lou L. Failed Back Surgery Syndrome. Pract Pain Manag. 2004 4.
Many of these patients undergo additional surgeries in order to correct the situation. However, success rates decrease significantly with each subsequent surgery. After unsuccessful surgery, patients present to chronic pain centers with a much more complicated diagnostic picture. Health care providers treat these patients at chronic pain centers with various medical procedures, counseling, physical therapy, medication, and psychiatric care as needed. However, questions remain about how best to help those who have experienced poor surgery outcomes and how they respond to various modalities of interdisciplinary treatment. For example, injection therapies are an increasingly popular mode of treatment for chronic back pain sufferers. There are, however, little empirical data available to health care providers about how those with a history of unsuccessful surgery respond to injections, particularly within an interdisciplinary treatment program. Furthermore, there are few studies addressing the efficacy of psychotherapy and physical therapy within an interdisciplinary program for patients who have undergone failed back surgeries.
Not Only Does The Mri Confuse Treatment Options After Spinal Fusion Failure It May Have Led Directly To The Failed Surgery
If the MRI showed what was really causing the pain, the lumbar fusion would have worked!
Here is a remarkable finding from research on lumbar fusion success or non-success.
Writing in The Open Orthopaedics Journal, Bo Nystrom of the Clinic of Spinal Surgery in Sweden wrote:
Results following fusion for chronic low back pain are unpredictable and generally not very satisfying. The major reason is the absence of a detailed description of the symptoms of patients with pain, if present, in a motion segment of the spine.
Various radiological findings have been attributed to discogenic pain, but if these radiological signs were really true signs of such pain, fusion would have been very successful.
If discogenic pain exists, it should be possible to select these patients from all others within the chronic low back pain population. Even if this selection were 100% perfect, however, identification of the painful segment would remain, and at present, there is no reliable test for doing so.
We cover this subject at length in my article MRI causes failed back surgery.
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Successful Failure Failure Of A Successful Surgery Which One Are You
We would like to remind our readers that people have very successful spinal surgeries. These are the people that we do not see at our center, we see the people who did not. These simple stories go something like this:
Failed lumbar fusion at L5-S1
Dear Caring Medical, I have failed lumbar fusion at L5-S1. The fusion did not help alleviate my chronic pain which is sometimes severe and debilitating. Im hoping to eliminate or manage the pain in my back to allow for normal daily functioning like sitting, driving, walking, and standing.
The surgery was a success, I still have pain
My surgeon said my L5-S1 fusion surgery was technically very successful. Unfortunately, scar tissue has developed and is pressing on my nerves.
My surgery was very successful, but I have spinal muscular atrophy as a result and weakness in my spine.
My surgery did not go well. I have had several surgeries since. I am on nerve blocks, pumps, pain meds.
When people contact us, we have to have a realistic expectation that we can help them. If someone had a broken screw, a crooked rod, or any other hardware failure, the hardware issues need to be addressed with their surgeons before a discussion of avoidance of further surgeries can be discussed.