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.
- Steroid only effective in a minority of patient
- 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 treatment options for patients with failed back surgery syndrome beyond secondary revision procedures, narcotic medications, spinal cor stimulators.
Recently, researchers from John Hopkins University issued these concerns to their fellow spinal surgeons:
- Patients who suffer from failed back surgery syndrome are showing up in the offices and clinics of physicians, surgeons, and pain specialists in overwhelming numbers.
- Failed back surgery syndrome has been defined as persistent back and/or leg pain despite having completed spinal surgery.
- As lumbar surgery continues to grow in prevalence, so will the number patients suffering from failed back surgery syndrome.
It is important for physicians treating these patients to expand their knowledge of what causes failed back surgery syndrome so they can adequately be prepared to manage these complex cases in the future.
Management of failed back surgery patients should, according to the John Hopkins team, begin with:
- a systematic evaluation looking for new-onset stenosis,
- recurrent herniated discs
- epidural fibrosis,
- pseudarthrosis, and others.
Certain diagnoses may be confirmed with diagnostic procedures such as intra-articular injections, medial branch blocks, or transforaminal nerve root blocks. Once a cause is determined, a multidisciplinary approach to treatment is most effective.
- This includes exercise or physical therapy,
- psychological counseling,
- and interventional procedures.
The most invasive treatment option, short of revision surgery, is spinal cord stimulation. This intervention has a number of studies demonstrating its efficacy and cost-effectiveness in this population. Finally, revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.1
Why does spinal surgery fail to relive pain?
Why do many have “disastrous results”
Awaking the beast
In new research doctors found that patients who underwent surgery for lumbar stenosis symptoms, often show radiologic evidence of cervical and thoracic spinal stenosis. However the cervical and thoracic stenosis did not cause pain or other symptoms typical of stenosis.
When these patients were sent to lumbar surgery, the prolonged surgical positioning during the lumbar decompression procedure, caused the cervical and thoracic spine to become symptomatic in many patients. 2 This is a classic example of surgery fixing one problem and causing a worse problem in another area of the spine.
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 spinal instability. Sometimes this leads to an “immediate failure,” of the back surgery – manifested as nerve root swelling due to excessive surgical manipulation.3
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 as noted in the above study.
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.
For the patients fixing one problem but causing the same problem to appear in another area of the spine can be seen as “disastrous results.” This is a term used by doctors in Mexico who investigated patients diagnosed with Failed Back Surgery Syndrome.
In their research they noted:
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
- 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%).4
Therefore the disastrous results could be seen arising from “surgical error,” and MRI misinterpretation.
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.5 The problem is MRI 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? Diagnosis Failed Back Surgery Syndrome.
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.6
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.
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.” 7
Failed Back Surgery Treatment Options
Long term Oxycodone – naloxone use? Naloxone is given to counter act the long-term effects of narcotic use. In one case study doctors found that a combination of Oxycodone – naloxone can be a good alternative for the management of Failed Back Surgery Syndrome when other interventional or pharmacologic strategies have failed. In this case report, higher doses than those recommended as a maximum daily ceiling (80/40 mg) were safely used in one selected patient with severe pain.8
Please see our article Painkillers can increase chronic pain for a further discussion on why doctors need to come up with a better plan of pain management rather than opioid dependence.
This is something the authors of the above cited study acknowledge: “Failed Back Surgery Syndrome” obviously needs a multidimensional clinical approach. Therapy failure might result from psychosocial influences, structural abnormalities in the back, or a combination of both.”
The next sentence is much more telling:
- “causes of back pain are largely unknown and correlations with diagnostic studies are uncertain. This lack of precise diagnosis is reflected into a multiplicity of nonspecific treatments, mostly of unproven value. There is limited evidence for oral opioids in the treatment of chronic low back pain; however, their routine use is widespread.”8
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 difficult to treat 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.9
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.”10
- 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.
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 research 11-13 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.
Platelet Rich Plasma Therapy
Recent research says that 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.14
In other research PLRP injections into atrophied lumbar multifidus muscle were found to be a safe, effective method for relieving chronic low back pain and disability with long-term patient satisfaction and success rate of 71.2%. The researchers recommended the use of the lumbar PLRP injections into the lumbar multifidus muscle as a possible means of identifying muscle weakness as the means of a patient’s low back pain. This they suggest could help avoid an unnecessary lumbar fusion to avoid failed back syndrome.15
References for this article on Failed back surgery
1. 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]
2. 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.
3. Rohde V, Mielke D, Ryang Y, Gilsbach JM. The immediately failed lumbar disc surgery: incidence, aetiologies, imaging and management. Neurosurg Rev. 2014 Sep 23.
4. 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]
5. 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.
6. 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.
7. Nyström B.Spinal fusion in the treatment of chronic low back pain: rationale for improvement. Open Orthop J. 2012;6:478-81.
8. Bujedo BM. Treatment of Failed Back Surgery Syndrome in a Forty-Three-Year-Old Man With High-Dose Oxycodone/Naloxone. Anesthesiology and Pain Medicine. 2015;5(2):e21009. doi:10.5812/aapm.21009.
9. Jeon YH. Spinal cord stimulation in pain management: a review. Korean J Pain. 2012 Jul;25(3):143-50. Epub 2012 Jun 28.
10. Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complement
11. 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.
12. 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.
13. Klein R, Eek B. Prolotherapy: an alternative approach to managing low back pain. J Musculoskeletal Medicine, 1997;May:45-49.
14. 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]
15. Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease. SICOT-J. 2016;2:12. doi:10.1051/sicotj/2016002.