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Failed Back Surgery Syndrome

FBSS Failed Back Surgery SyndromePatients with persistent lumbar pain do not take the choice to have invasive spinal surgery lightly. After lengthy discussion and consultation, sometimes with multiple practitioners, they make the informed and difficult decision to undergo procedures like discectomy, microdiscectomy, laminectomy, or spinal fusion with high hopes. Sometimes, however, after the pain of the operation itself has subsided, they come to the gut-wrenching realization that their initial pain persists, or has actually worsened. The back surgery they had so counted on failed to work.

Failed Back Surgery Syndrome (FBSS) is not actually a syndrome. It is a catch-all phrase that is used to describe the condition of patients who continue to have chronic pain after the surgery that was supposed to relieve it. More properly, the outcome did not achieve the expectations agreed upon by both the patient and their doctor before the procedure. [1] There are a variety of reasons why spinal surgery is unsuccessful, and it is crucial for the physician to understand why in order to determine the course of further treatment

Regardless of why surgery failed, the only thing that matters to the patient is what to do next. When further surgery is not the best option moving forward, a multi-disciplinary program of medical management could yield the best results to return the patient to normal functioning. [2] The doctors at the Ainsworth Institute of Pain Management are experts at diagnosing the cause surgical failure, and can offer you a combination of treatment options that will help you get your life back.

What is Failed Back Surgery Syndrome?

Failed Back Surgery Syndrome FBSSBefore back surgery, a doctor must communicate what the patient can realistically expect from the procedure according to the medical evidence. The two must agree upon reasonable and hoped for outcomes. [2] When these outcomes fail to meet the expectations of the doctor and patient i.e. pain continues, mobility is unaffected, we can say the back surgery has failed.

Failed Back Surgery Syndrome pain is not always a persistence of the same pain the patient had going into the procedure. It is important to note that there are several different qualities the pain associated with Failed Back Surgery Syndrome can take on. The pain may be reduced after surgery but still present enough to affect the patient’s quality of life. Conversely, the pain might actually increase in the months following a procedure, perhaps because a buildup of scar tissue around nerve roots. Also, a new pain distinct from the initial complaint may arise.   To make matters more confusing, any of these examples do not necessarily imply there was a problem during surgery. [3]

The Incidence of Failed Back Surgery Syndrome

The incidence of Failed Back Surgery Syndrome is estimated at 20-40%. The likelihood increases with repeated surgeries. Also, the condition is more common in areas where spinal surgery is more prevalent. [4] There is also evidence reported by the U.S. National Institute of Health that the likelihood of FBSS increases according to the invasiveness of the surgery. [5]

What are the Symptoms?

As mentioned above, patient’s experiencing Failed Back Surgery Syndrome report either a persistence or worsening of pain after surgery. They may also report a new type of pain as well. Other symptoms associated with failed back surgery syndrome include:

 Aching pain in neck, back or legs
 Dull pain in neck, back or legs
 Pain above or below location of surgery
 Pricking or stabbing in extremeties
 Loss of mobility
 Anxiety and depression
 Spasms

What are the Causes?

There are several possible causes back surgery could be unsuccessful.

 Condition not properly identified – When a clinician has picked an operation that does not correctly address the problem, that operation is more than likely to fail. In the complex system that is the human spine, an accurate diagnosis of the pain generator is not always straightforward. What’s more, conditions such as osteoarthritis can mimic degenerative spine conditions. An inexperienced clinician can end up operating on the wrong area and not fixing the problem. [6]

Failed Back Surgery Syndrome FBSS  Condition partially identified – Patients can have more than one degenerative spine condition at once. Once again, an inexperienced clinician may choose to address only one area that he/she deems the worst leaving the patient to still experience pain from secondary conditions. [2]

 Nerve damage – When a nerve root is decompressed during surgery inflammation often occurs. In some cases the nerve itself can be damaged resulting in chronic pain. [7]

 Technical error – Sometimes a surgeon can mistakenly leave behind a bone fragment or residual material from a herniated disc. This can cause pressure against the nerve root and pain to worsen.

 Implant slippage – If a spinal implant shifts before it has affixed itself to the adjacent vertebrae it could compress sensitive tissue, therefore causing pain.

 Epidural Fibrosis – The body naturally forms scar tissue after any kind of spinal surgery as part of the healing process. This tissue can sometime bind to the nerve root resulting in the condition called epidural fibrosis resulting in post-operative pain. [8]

 Recurrent disc herniation – Removal of one vertebral disc can often lead to herniation of another down the road. Also, material left from a discectomy can re-herniate. [9]

 Spinal Stenosis – Patients who receive a discectomy or other surgeries can often develop spinal stenosis as a late complication.

 Arachnoiditis – Fibrous scarring that occurs within the subarachnoid space (below the epidural space) – it is notoriously difficulty to detect. and is irreversible.

What are my Treatment Options?

Treatments of FBSS Failed Back Surgery SyndromeWith Failed Back Surgery Syndrome (FBSS) you need to consult a physician with spinal expertise who can ascertain why you are continuing to experience pain post surgery. As shown above, there can be many reasons. If you were improperly diagnosed, the true cause of your pain needs to be evaluated. If you sustained an injury during the surgery itself, then that must be correctly apprehended, as well as if you are suffering from some secondary condition that was indirectly caused by the procedure.

Once your underlying condition has been understood, your doctor can best decide on the appropriate course of treatment.

Interventional Pain Management Treatments

Lumbar Epidural Steroid Injection – This procedure is considered a very effective treatment for back pain. It is basically the same treatment a woman will receive during childbirth to eliminate pain.  Under fluoroscopic guidance, your physician will place a small needle into the epidural space and inject a small amount of medication to eliminate the pain.

Transforaminal Epidural Steroid Injection – This procedure is similar to the one above; however, in this case the medication is focused directly onto the nerve fibers that make up the sciatic nerve – the result is more medication delivered to the affected area.

Radiofrequency Ablation (RFA) – Radio waves are applied to a nerve, subsequently stunning it and preventing from transmitting pain.

Lysis of Adhesions (Adhesiolysis) – A small flexible-tip catheter is gently inserted through the tail bone into the epidural space toward the site of surgery and any potential scar tissue.  Wherever the catheter comes into contact with a adhesion or scar tissue, the flexible tip will break it up and move it out of the way.

Spinal Cord Stimulation (SCS) – When the inflammation in and around the affected nerves is too great for an epidural injection, SCS is an excellent and effective treatment option that can eliminate the pain without surgery. In SCS, an electrical pulse is delivered directly to the spine, blocking certain neuron fibers’ access to the brain and consequently the brain’s ability to sense the previously perceived pain. 

Intrathecal Pumps – A small catheter is placed in the subarachnoid space (just below the epidural space) and extremely small amounts of medication are slowly delivered directly over the spinal cord. This enables your physician to provide the same medications you might take orally to manage the pain but at a fraction of the dose – thus decreasing the side effects.  More importantly, our doctors have been putting a revolutionary drug inside the pumps called ziconotide and are reported amazing successes!

The Ainsworth Institute is Here to Help

The doctors at the Ainsworth Institute of Pain Management specialize in the identifying and treating failed back surgery syndrome. Dramatic improvements in pain and quality of life are a single phone call away. Schedule an appointment today with one of our board certified pain management experts to discuss what options for treatment may best suit your needs.

References

[1] Schofferman J, Reynolds J, Dreyfuss P, et al. Failed Back Surgery: etiology and diagnostic evaluation. Spine J 2003;3:400-403.

[2] Schofferman J: Failed Back Surgery. In: Bonica JJ: The Management of Pain. 4Th ed. Philadelphia, Lea & Febiger; 2009: 1130-1142.
[3] Fritsch EW, Heisel J, Rupp S (Mar 1996). “The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments”. Spine 21 (5): 626–33.

[4] Chan CW, Peng P. Failed back surgery syndrome. Pain Med 2011;12:577-606

[5] Slipman CW, Shin CH, Patel RK, et al. (Sep 2002). “Etiologies of failed back surgery syndrome”. Pain Med 3 (3): 200–14; discussion 214–7.

[6] Guyver R, Patterson M, Ohnmeiss D. Failed back surgery syndrome: diagnostic evaluation. J Am Acad Orthop Surg 2006; 14:534-543.
[7] Cauchoix J, Ficat C, Girard B (1978). “Repeat Surgery After Disc Excision”. Spine 3 (3): 256–59.

[8] Lähde S, Puranen J (August 1985). “Disk-space hypodensity in CT: the first radiological sign of postoperative diskitis”. Eur J Radiol 5 (3): 190–2.

[9] Epps C. H. (1978). Complications in Orthopedic Surgery. Philadelphia: Lippincott and Co. pp. 1009–1037.

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