Failed back surgery syndrome treatment options
Dr. Hauser explains treatment options in patients with failed back surgery syndrome.
In this article Dr. Hauser will cover possible reasons why your surgery did not achieve its goals and realistic assessments of stem cell therapy, Platelet Rich Plasma Therapy, and Prolotherapy for repairing spinal instability and pain after spinal surgery.
- Seeing patients after spinal fusion surgery failure
- Steroid appears to be effective in only a minority of patient
- Doctors should not recommend surgery if patients exhibit no pain despite positive MRI finding
- As lumbar surgery continues to grow in prevalence, so will the number patients suffering from (failed surgery)
- Limitations to spinal cord stimulators
- Patients will still have “persistent back and/or leg pain despite having “completed” spinal surgery
- There are options including stem cell therapy, PRP treatments, and Prolotherapy.
Spinal surgery cannot only fail to relieve pain; it may in fact cause more pain and cause “disastrous results”
Awaking the beast
In new research (October 2015) doctors found that patients with symptomatic lumbar stenosis often have asymptomatic radiologic cervical and thoracic spinal stenosis. That is stenosis of the cervical and thoracic spine that does not cause symptoms. However when these patients are sent to surgery, the prolonged surgical positioning during lumbar decompression, may cause the cervical and thoracic spine to become symptomatic. 1 This is a classic example of fixing one problem and causing a worse problem in the spine.
Doctors in Mexico are investigating what they call “disastrous” results in Failed Back Surgery Syndrome. They speculated on the quality of medical care .
The majority of the cases in one group had a previous diagnosis of lumbar stenosis whereas disc herniation was the main diagnosis in group number 2.
- The main reason for failed back surgery in the Stenosis group was was technical error during surgery (61.1%).
- In group 2 the disc herniation group -misdiagnosis was highly prevalent (57.4%).2
Therefore the disasterous results could be seen arising from “surgical error,” and MRI misinterpretation. See below and also see our more detailed Failed Back Surgery Risk Factors – the MRI.
Research appearing in the journal, Seminars in Musculoskeletal Radiology, lists potential complications following spinal fusion which could confuse the interpretation of the MRI for doctors who are trying to see why the patient is suffering from post-surgical pain.
Radiologists are told to look for specific complications related to the use of spinal instrumentation (the hardware) that include incorrectly positioned instrumentation and failure of spinal fusion, leading to instrumentation loosening or breakage. This is in addition to leakage of cerebrospinal fluid, infection, continued disc herniation.3 The problem is the MRI–it cannot tell what is causing the patient’s pain anatomically – it now has to look for suspect hardware. What if there is no suspect hardware?
In a discectomy (removal of the disc), the surgeon must spread muscle and cut various ligaments in order to perform the surgery. The surgery itself can potentially lead to ligament laxity and instability of the spine. Sometimes this leads to an “immediate failure,” of the back surgery – manifested as nerve root swelling due to excessive surgical manipulation.4
Further removal of a disc or fusion at one level can lead to disc herniation at the same level or at different levels in the future. It is very common for doctors to see a patient with “one level fixed,” while another segment of the spine is now unstable, degenerated, and causing pain.
Another way surgery causes harm is that in a discectomy, a large portion of the disc remains behind. This is the portion that, if removed, will cause great risk to the patient. The remaining disc can be as much as 40% of the original disc and it can also re-herniate.
Spinal surgery is very radical, it injures and damages a lot of tissue not even associated with the painful area. So what if there is pain following surgery? What are the options?
In recent research, doctors noted that failed back surgery patients were showing up at doctor’s offices in “overwhelming numbers.”
These patients complained of “persistent back and/or leg pain despite having “completed spinal surgery.” They also noted “As lumbar surgery continues to grow in prevalence, so will the number patients suffering from (failed surgery).”5
To fix the patient: ”The most invasive treatment option, short of revision surgery, is spinal cord stimulation. . . revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.”6
- Therefore it is not uncommon for people to undergo a complicated spinal surgery only to be left with chronic low back pain. The diagnosis for this scenario is “failed back surgery syndrome,” or FBSS.
Failed back surgery caused by MRI
Best evidence does not support the use of MRIs for patient surgical selection
One of the most difficult things to tell a patient with significant back pain is that the MRI may not be telling the true story. This, despite an abundance of research suggesting it is not possible to accurately predict who spinal fusion will or won’t work for, using standardizing radiological scans:
- “No subset of patients with chronic low back pain could be identified for whom spinal fusion is a predictable and effective treatment. Best evidence does not support the use of current tests for patient selection in clinical practice.”7
- “Although MRI is appealing, its utility in assessing fusion remains unproven.”8
Reliance on MRI for determining surgical treatment for spinal pain has been shown to be faulty, inaccurate, and leads to unnecessary surgery. This is why it is very important that the patient seek an opinion from a doctor who performs a physical examination to determine the exact cause of pain.
In one research study, doctors said that nearly one in four patients who had a lumbar discectomy had positive scans for recurrent disc herniation following the surgery, the majority of which displayed no pain symptoms.
MRI validated disc herniation which did not cause pain or other symptoms was not associated with clinical consequences in two years following surgery. Clinically silent (patient’s not reporting) recurrent disc herniation is common after lumbar discectomy.
In other words doctors are telling each other that when they order a MRI within the first 2 years of discectomy, they should expect that the MRI will show abnormalities that are of no consequence to the patient and that they should not rush to surgery.9
This is backed by other research which states Imaging often reveals degenerative findings of the disc or facet joints of one or more lumbar motion segments. These findings, however, can also be observed in people with no symptoms.10
Not only does the MRI confuse treatment options after spinal fusion failure – It may have lead 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 the latest research on lumbar fusion success or non-success.
“Results following fusion for chronic low back pain (CLBP) 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 CLBP 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..”
Of importance in the above results: “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.”11
If the patient does not complain of back pain – but the MRI shows herniated disc – Do not recommend surgery!
Here is what researchers in Germany found when they tested steroid injection in patients with chronic back and radicular pain after surgery: “Of 479 patients who underwent microsurgical lumbar disc surgery, 69 had persistent radicular pain. . . injection of steroid achieved pain reduction of at least 50% in 26.8% of these patients. The success rate was higher (43%) in patients without a recurrent disc herniation.” Here is the big finish:
- ” injection of steroid appears to be effective in only a minority of patients with radicular pain persisting after disc surgery…” PLEASE NOTE 479 PATIENTS – 69 HAD persistent radicular pain – ABOUT 15% 12
- In other words – if the patient does not complain of back pain – but the MRI shows herniated disc – leave the patient ALONE!
If low back surgeries are so unsuccessful, why do surgeons continue to perform them? The main reason is because they find abnormalities on MRI scans – as mentioned above.
Ironically most MRI findings have nothing to do with why the person has pain and this is the reason for most back surgery failures. Nearly one in three back pain patients should not even get an MRI according to one report because it may lead to unnecessary spinal surgery. “MRI alone may provide insufficient or inaccurate information upon which to base surgical/technical decisions in about of 30% of cases (of back pain).”13
Recurrence of back or leg pain after surgery is a well-recognized problem with an incidence of up to 28%
“Recurrence of back or leg pain after discectomy is a well-recognised problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success….The debate around which procedure is the most effective for these patients remains controversial.14
Note that the above study cites 28% rate of post-surgical pain. The researchers also note that controversy exists over the best revision surgery for pain after surgery. Their conclusion is that surgeons may as well choose the least invasive surgery since there’s no one revision surgery that is better than the other. As mentioned above, surgery of any kind interferes can cause harm to soft tissue, revision surgery is likely not the best answer.
Platelet Rich Plasma Therapy IN spinal fusion to increase successs rate
New research in March 2015 says that while spinal fusion is one of the most commonly performed procedures for the treatment of spinal instability, and despite significant advances in spinal instrumentation, failed fusion remains a significant challenge.
Therefore, other additives such as bone graft extenders and growth factors have been explored as a method to augment fusion rates. Platelet-rich plasma (PRP) represents an additional approach, as it has shown some promise in bone regeneration, and should be explored for its potential role in limiting spinal fusion surgery failures.15
Limitations of Spinal Cord Stimulators
Spinal cord stimulation is usually reserved as a last-chance effort at controlling back pain. Specifically it is used for people what have pain after surgery, complex regional pain syndrome (also known as reflex sympathetic dystrophy), or severe nerve pain and numbness. The procedure involves implanting a small pulse generator into the stomach and running coated wires to the spine to deliver electrical impulses to the spinal cord. These electrical impulses block pain signals traveling to the brain. Of course, there are risks to implanting a foreign device in the body. Some of these risks include infection, scar tissue around the stimulator, headaches, breakage of electrical wire, and pain beyond the reach of the impulses.
Doctors note that Spinal cord stimulation can be an efficient alternative for the management of refractory chronic pain that is unresponsive to conservative therapies. Technological improvements have been considerable and the current devices are reliable in obtaining good results for various clinical situations of chronic pain, such as failed back surgery syndrome.
When surgery fails, when narcotics fail, electrical technology is brought in. The spinal cord stimulator provides a small electric current to the person’s spinal cord so the impulses of pain and injury are lessened. In most patients we see, the spinal cord stimulator does not replace the need for narcotic medication. Additionally, a foreign device is placed in the body, which is nearly never the best option.
Intrathecal drug delivery
Similar to a spinal cord stimulator, spinal drug delivery (or intrathecal 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, specifically for people with failed surgery or complex regional pain syndrome. Compared to oral medication, this “pain pump” requires a smaller dose of narcotics because medication goes directly to the area of pain. This therapy is also for people with pain after surgery or complex regional pain syndrome.
Mind over body pain control
“Mindfulness-based stress reduction (MBSR) is frequently used for pain conditions. While systematic reviews on MBSR for chronic pain have been conducted, there are no reviews for specific pain conditions. Therefore a systematic review of the effectiveness of MBSR in low back pain was performed….This review found inconclusive evidence of effectiveness of MBSR in improving pain intensity or disability in chronic low back pain patients. However, there is limited evidence that MBSR can improve pain acceptance.”16
- In other words, just live with the pain. Mental strength can help, but the reality is that there is an underlying cause of the pain that needs to be addressed. So what are other options for pain after back surgery?
Comprehensive Prolotherapy for failed disc surgery: realistic goals
Comprehensive Prolotherapy is a treatment designed to strengthen weakened soft tissue in the spine and bring stability to the area through injections, not surgery. More stability, less unnatural movement, less pain. We recommend a consultation for those on narcotics and those with spinal cord stimulators. In the case of spinal stimulators, we ask patients to bring in their X-rays showing exactly where the spinal cord stimulator is placed. As long as we can see where the stimulator electrodes are located we can safely do Prolotherapy.
Prolotherapy attacks the problems of a damaged spine instead of suppressing the symptoms. It offers a fix when all else fails. While Prolotherapy is an alternative to disc surgery, it can also help when disc surgery has already occurred yet failed to address the root issue.
Alternative to fusion surgery
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.
Prolotherapy research17-19 has shown Prolotherapy can stabilize the areas that are painful without causing a “complete” fusion. What weakened, loose, or painful spinal segments need is stabilization, not fusion. They just need to be stronger. One way to get them stronger is to receive Prolotherapy treatments and injections into and around the vertebral facet joints and transverse processes to stimulate repair. Once these vertebral segments are strong, the pain starts to go away.
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.
How does Prolotherapy help radiculopathy?
Radiculopathy by definition means a nerve is being compromised leading to symptoms in the extremity. We find that 90% of people coming in with the diagnosis of radiculopathy (Lumbar Radiculopathy) do not have a pinched nerve. The majority has referred pain down the extremity (leg or arm) from a ligament injury in their pelvis, lower back, neck, or upper back. Three to six Prolotherapy sessions and the majority of these pains subside. For the other 10 percent that have a true radiculopathy the following is typically present:
- Crippling pain.
- The MRI shows an acute herniated disc
- The MRI finding is consistent with the person’s symptoms and exams
- The EMG collaborates the MRI
In the case of a true pinched nerve, most Prolotherapists will get the person some pain control while the Prolotherapy is working. The person with a true radiculopathy needs to decrease the inflammation of the disc material pressing on the nerve while the Prolotherapy helps stabilize the herniated areas. The best approach, in our opinion, is to give a steroid injections right around where the disc herniation is located. This is called a nerve block. Sometimes an epidural is done, but we like putting the medication directly where the problem is located. The person is also prescribed muscle relaxers and rarely oral steroids. These steps are only immediate-level treatments. Simultaneously Prolotherapy works on the long-term cure. Yes the steroids block some of the Prolotherapy effect, but the person needs immediate pain relief. A medication to help sleep is also warranted sometimes. Obviously, the person gets Prolotherapy to the areas. The person is seen in follow-up in one week. At this time if they still have a lot of pain, then another steroid injection is given to the painful area. Up to three of these are done. At the two-week point, sometimes another Prolotherapy session is done. Up to four Prolotherapy sessions are sometimes needed. The above approach has been used at Caring Medical Rehabilitation Services for years. It has kept a lot of people out of surgery. In our experience the above approach even with herniated discs is around 90% successful. Of course, we have our handful of cases that have needed surgical consultation and surgery. We are grateful the surgeons are there for back-up. Even for an acute herniated disc the surgeon is second line therapy, or the person with a pseudo- or true radiculopathy the treatment of choice is Prolotherapy!
References for this article on Failed back surgery
1. Park MS, Moon SH, Kim TH, et al. Asymptomatic Stenosis in the Cervical and Thoracic Spines of Patients with Symptomatic Lumbar Stenosis. Global Spine J. 2015 Oct;5(5):366-71. doi: 10.1055/s-0035-1549031. Epub 2015 Mar 27.
2. Romero-Vargas S, Obil-Chavarria C, Zárate-Kalfopolus B, Rosales-Olivares LM, Alpizar-Aguirre A, Reyes-Sánchez AA. [Profile of the patient with lumbar failed surgery syndrome at National Institute of Rehabilitation. Comparative analysis]. Cir Cir. 2015 May 15. pii: S0009-7411(15)00007-9. doi: 10.1016/j.circir.2015.04.006. [Epub ahead of print]
3. Rankine JJ. The postoperative spine. Seminars in Musculoskeletal Radiology. 2014 Jul;18(3):300-8. doi: 10.1055/s-0034-1375571. Epub 2014 Jun 4.
4. Rohde V, Mielke D, Ryang Y, Gilsbach JM. The immediately failed lumbar disc surgery: incidence, aetiologies, imaging and management. Neurosurg Rev. 2014 Sep 23.
5. Hussain A, Erdek M. Interventional Pain Management for Failed Back Surgery Syndrome. Pain Pract. 2013 Feb 3. doi: 10.1111/papr.12035. [Epub ahead of print]
6. Jeon YH. Spinal cord stimulation in pain management: a review. Korean J Pain. 2012 Jul;25(3):143-50. Epub 2012 Jun 28.
7. Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2012 Nov 2. pii: S1529-9430(12)01276-4. doi: 10.1016/j.spinee.2012.10.001. [Epub ahead of print]
8. Selby MD, Clark SR, Hall DJ, Freeman BJ. Radiologic assessment of spinal fusion. J Am Acad Orthop Surg. 2012 Nov;20(11):694-703. doi: 10.5435/JAAOS-20-11-694.
9. Lebow RL, Adogwa O, Parker SL, Sharma A, Cheng J, McGirt MJ.Asymptomatic same-site recurrent disc herniation after lumbar discectomy: results of a prospective longitudinal study with 2-year serial imaging.Spine (Phila Pa 1976). 2011 Dec 1;36(25):2147-51.
10. Willems P. Decision making in surgical treatment of chronic low back pain: the performance of prognostic tests to select patients for lumbar spinal fusion.Acta Orthop Suppl. 2013 Feb;84(349):1-35. doi: 10.3109/17453674.2012.753565.
11. Nyström B.Spinal fusion in the treatment of chronic low back pain: rationale for improvement. Open Orthop J. 2012;6:478-81.
12. Klessinger S. Radicular Pain in Post Lumbar Surgery Syndrome: The Significance of Transforaminal Injection of Steroids Pain Med. 2012 Aug 8. doi: 10.1111/j.1526-4637.2012.01463.x. [Epub ahead of print]
13. Weiner BK, Patel R. The accuracy of MRI in the detection of Lumbar Disc Containment. Journal of Orthopaedic Surgery and Research 2008, 3:46
14. Lakkol S, Bhatia C, Taranu R, Pollock R, Hadgaonkar S, Krishna M. Efficacy of less invasive posterior lumbar interbody fusion as revision surgery for patients with recurrent symptoms after discectomy. J Bone Joint Surg Br. 2011 Nov;93(11):1518-23.
15. Elder BD, Holmes C, Goodwin CR, Lo SF, Puvanesarajah V, Kosztowski TA, Locke JE, Witham TF. A Systematic Assessment of the Use of Platelet-Rich Plasma in Spinal Fusion. Ann Biomed Eng. 2015 Mar 21. [Epub ahead of print]
16. Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complement
17. Klein R, Dorman T, Johnson C. Proliferant injections for low back pain: histologic changes of injected ligaments and objective measurements of lumbar spinal mobility before and after treatment. J Neurologic and Orthopedic Medicine and Surgery. 1989;10:123-126.
18. Klein R, Eek B, DeLong B, Mooney V. A randomized double-blind trial of dextrose-glycerine-phenol injections for chronic, low back pain. J Spinal Disord. 1993;6:23-33.
19. Klein R, Eek B. Prolotherapy: an alternative approach to managing low back pain. J Musculoskeletal Medicine, 1997;May:45-49.