Failed Back Surgery Syndrome
Ross Hauser, MD
It’s 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. Many of these patients have terrible radicular pain – pain that travels into the limbs and extremities with the spine as their source. Physicians experienced in treating FBBS are familiar with the causes, understanding all that goes on during back surgery. During disc surgery, for example, the surgeon must spread muscles, cut ligaments, and disrupt the natural anatomy in order to perform the surgery. The surgery itself can cause ligament laxity and instability of the spine. 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%.1
Not only did back surgery fail to fix the problem, it made it worse
“Nearly one-fourth of patients undergoing lumbar discectomy demonstrated radiographic evidence of recurrent disc herniation at the level of prior surgery, the majority of which were asymptomatic. Asymptomatic disc herniation was not associated with clinical consequences by 2 years. Clinically silent (patient’s not reporting) recurrent disc herniation is common after lumbar discectomy. When obtaining MRI evaluation within the first 2 years of discectomy, providers should expect that radiographic evidence of reherniation may be encountered and that treatment should be considered only when correlating radicular symptoms exist.”2 In other words – if the patient does not complain of back pain – but the MRI shows herniated disc – leave the patient ALONE! No Surgery! 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).”3
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!
1. Radicular Pain in Post Lumbar Surgery Syndrome: The Significance of Transforaminal Injection of Steroids. 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]
2. 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.
3. Weiner BK, Patel R. The accuracy of MRI in the detection of Lumbar Disc Containment. Journal of Orthopaedic Surgery and Research 2008, 3:46