LBP: Failed Back Surgery
It is estimated that in 2008 the number of adults in the United States with chronic back pain was 12.8 million. In the one year of 2008, the number of lumbar fusions performed was 210,407.and the number of lumbar laminectomies performed was 107,790. By 2016, the numbers are estimated to have considerably increased.
However, regarding the success of these surgeries reports indicate:
- 5%–36% recurrence rate of back or leg pain 2 years after discectomy for disc herniation
- 29.2% of patients had same or increased pain 12 months after surgical laminectomy for lumbar stenosis secondary to degenerative changes
When surgery fails to provide relief or provides only temporary relief of the patient’s pain, it is referred to as “Failed Back Surgery Syndrome (FBSS). The International Association for the Study of Pain defines FBSS as:
“Lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location.”
The incidence of FBSS is estimated to be 20%-40% and subsequent surgery to address these types of failed outcomes have been reported to only have a 35% success rate in terms of perceived recovery, functional disability, and pain 15 months after instrumented fusion.
In other terms, 1 out of 3 surgeries fail to provide adequate relief of pain and, of those failures, only 1 out of 3 are successfully corrected with more surgery.
This section of the website is not designed to discourage surgery or downplay the effectiveness of surgery for LBP. Rather it is here to help educate the patient in ways to avoid becoming another victim of FBSS. And for those who may suffer from FBSS already, this section is also directed at improving patient understanding and treatment of FBSS.
For those considering surgery for their LBP, the decision may be one of the most important decisions of their life, with consequences that may overshadow all other decisions. For more information about FBSS, assessment and management, continue reading below.
Low Back Pain (LBP) – Overview
LBP – Superior Cluneal Nerve Entrapment
LBP – Failed Back Surgery Syndrome
LBP – Sacroiliac (SI) Joint Pain
Facet Joint Injections and Nerve Procedures
LBP: Failed Back Surgery Syndrome (FBSS)
Failed Back Surgery Syndrome (FBSS) may be a consequence of both preoperative and postoperative risk factors. Clearly, all efforts should be made prior to surgery to assure the greatest likelihood of success, including addressing the risks for failure. However, for those suffering from FBSS, the understanding of postoperative variables may facilitate successful reduction of pain.
Many preoperative variables influence the likelihood of successful spinal surgery including the accuracy of diagnoses, socioeconomic, behavioral, and psychological factors. Understanding these variables may prepare one for greater likelihood of a successful surgery.
Accuracy of Diagnosis
While diagnostic accuracy is an obvious variable, inaccurate diagnosing is probably the major factor leading to FBSS. For example, it is estimated that as much as 58% of FBSS results from undiagnosed lateral stenosis of the lumbar spine (see Spinal Stenosis). As a patient, it would appear that the responsibility of accurate diagnosing lies with the surgeon. Superficially, this is true but on deeper inspection it becomes clear that the surgeon’s diagnosis is based largely on the information provided by the patient. It is well established that neither the physical examination nor findings on imaging studies such as x-rays, CT scans and MRIs necessarily correlate with the source or severity of perceived pain.
While the patient’s history and description of LBP is also not in of itself always reliable in establishing a diagnosis, the important thing to understand is that the patient’s experience and perspective of their pain is the most important factor that connects the diagnostice process all together. It can direct the physician to an accurated diagnosis or completely lead to the wrong diagnosis. The better a patient observes their own symptoms by paying attention to the variables that influence those symptoms and the better they can communicate these observations with the physician, the more likely an accurate diagnosis will be identified. This website has many links to pages that explore different sources of LBP, their causes and their distinguishing features. They can be a resource to provide insights for the patient to better observe and communicate their symptoms to the physician and potentially improve the physician’s diagnostic accuracy.
Because the basis of the decision to undergo surgery and the type of surgery to be performed are different for each patient, it is beyond the scope of this website to provide individualized guidance. It may be helpful however to note that certain diagnoses are associated with greater rates of FBSS. For example, multiple studies have shown that back pain caused by foraminal stenosis is associated with greater rates of FBSS than pain caused by recurrent disc herniation.
The development of myofascial pain often accompanies and/or follows most if not all of the other common reasons for LBP including disc and facet pain. In fact, the presence of myofascial pain can be the dominant pain generator whose severity drives a patient to seek surgical solutions which would be destined not only to fail but to worsen pain. Because myofascial pain and its referral patterns often overlack or mimic referral patterns from discs and facets, myofascial pain is often overlooked as the pain generator and surgery is performed. A careful evauation for myofascial pain should always be assessed carefully and treated accordingly by a clinician knowedgeable about myofascial pain – most often not a surgeon. It is the opinion of many physicians that a great number of unsuccessful outcomes of surgery for LBP are a direct result of failing to identify and treat myofascial pain.
Because myofascial pain can also develop as a complication of lumbar surgery, the same caveat applies regarding the careful assessment and treatment this condition.
See Myofascial Pain
Smoking is associated with an increased rate of perioperative complications such as impaired wound healing, increased rate of infections, and an increased rate of bony nonunion. Compared with nonsmokers postoperativly, smokers require more analgesics and have inferior overall quality of life two years after surgery.
Obesity is a complicating for all surgeries requiring general anesthesia and is associated with greater risk for complications. As it is also a significant contributor to chronic pain, it makes sense to make every effort to reduce excessive weight prior to undergoing surgery.
Depression is one of the strongest predictors of a negative outcome after spinal surgery. Depressed patients generally feel more pain and weakness postoperatively and are less likely to return to work than those without depression. Preoperative treatment of depression, anxiety, and other psychological conditions may be useful in the prevention of FBSS.
The recurrence of back pain or the failure of back pain to resolve can be due to many variables. Pain may result from further degeneration of the spine or new spine problems, or as a result of trauma or stress from adjacent muscles.
Back surgery commonly results in biomechanical changes in the area of surgery, resulting in an increased load burden in adjacent structures that can accelerate degenerative changes in the areas of the spine, both above and below the fusion. Fusion of the lumbar spine to the sacrum or fusion of multiple lumbar segments may lead to sacroiliac joint (SIJ) dysfunction. These biomechanical changes may also result in increased tension on the prevertebral and postvertebral muscles that control movement of the spinal column leading to myofascial pain, an extremely common source of pain in FBSS. Physical therapy, myofascial therapy, education and attention to posture and the mechanics of lifting, carrying etc. may reduce these changes and limit the development of postoperative pain.
Arachnoiditis, Postsurgical Inflammation and Fibrosis
Scarring, or postsurgical fibrosis, commonly complicates spinal surgery. Epidural adhesions can develop as a result of postoperative inflammation leading to arachnoiditis. Arachnoiditis is a condition characterized by inflammation of the arachnoid membrane surrounding spinal cord nerves, which can lead to a host of serious issues, including severe pain, lower-extremity paralysis, bowel dysfunction, and systemic autoimmune disorder. Once considered rare, there is growing recognition that this condition may be underdiagnosed with a greater prevalence than expected. The arachnoid can become inflamed because of an irritation from chemicals, infection from bacteria or viruses, as the result of direct injury to the spine, chronic compression of spinal nerves, or complications from spinal surgery or other invasive spinal procedures.
The inflammation associated with arachnoiditis can cause the spinal nerves in the lower lumbar spine, the cauda equina, to “stick” together, worsening symptoms. The pain of arachnoiditis has been reported as constant, severe and associated with standing too long, causing the patient to sit or lie down. Additional symptoms may include numbness, tingling, and a characteristic stinging and burning pain in the lower back or legs, tremors or “jerking” in the legs, intense episodes of heat and sweating, difficulty urination and/or defecation, sexual dysfunction and episodes of blurry vision. In severe cases, arachnoiditis may cause paralysis of the lower limbs.
Treatment of arachnoiditis includes hormones, corticosteroids, anti-inflammatory agents and specific stretching exercises. Surgery is generally not recommended as a treatment for arachnoiditis because of the possibility of worsening of scar tissue and fibrosis formation.
Diagnosing Sources of FBSS
To differentiate postsurgical fibrosis from disc herniation or other pathology as a cause of postoperative back pain, imaging with MRI or CT scans, CT myelography or discography may be required. Nerve blocks may also help identify sources of pain.
MRI is much superior to conventional CT scanning in the evaluation of arachnoiditis because of the poor contrast resolution in CT scans between the spinal cord and nerve roots and CSF. However, CT myelography is effective in demonstrating the classic imaging findings of arachnoiditis. These include narrowing or blockage of the subarachnoid space, irregular collections of contrast material, thickened or matted nerve roots, and absent filling of nerve root sleeves.
Treatment of FBSS
Successful management of FBSS, lika all chronic LBP, often requires an “integrative” approach, that is a treatment regimen that incorporates a multi-disciplinary collection of treatment options that include education, exercise, trigger point therapy, massage, spinal manipulation, acupuncture, diet and nutritional supplements, medications and mind-body disciplines such as yoga and tai chi. These topics are covered elsewhere on this website. However, for specifics regarding the diagnosis and management of the different anatomic sources of chronic LBP see:
Facet joint injections and nerve procedures
LBP – Failed Back Surgery Syndrome (FBSS)
- Failed back surgery syndrome – definition, epidemiology and demographics – 2013
- Failed back surgery syndrome – current perspectives – 2016
- Narcotic Addiction in Failed Back Surgery Syndrome – 2019
- Optimizing the Management and Outcomes of Failed Back Surgery Syndrome – A Consensus Statement on Definition and Outlines for Patient Assessment – 2019
LBP – Arachnoiditis
- Chronic Back Pain May Be Arachnoiditis- 2015
- Arachnoiditis – NORD (National Organization for Rare Disorders)
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
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