Failed back surgery syndrome

Considering the large number of chronic pain patients who suffer from back pain, I find it somewhat odd that my back doesn’t usually bother me.  Maybe if the pain in my head wasn’t at such a high level, I might notice pain in other areas of my body.  Maybe if I had agreed to surgery for the degenerative disk disease in my neck, I might now be suffering from chronic back pain.  Who knows.

But I find the information on Failed Back Surgery Syndrome to be incomplete and not very logical.  Just the name of the condition, including the word “failed,” which seems to blame the pain patient for problems experienced after surgery.  After my TMJ surgery, my pain got worse, so I can certainly empathize with those who suffer from this poorly-named condition.

This is an abstract from 1991:

The failed back or postlaminectomy syndrome is obviously multidimensional. Failure of therapy may result from structural abnormalities in the back, psychosocial influences, or a combination of both. The causes of back pain are largely unknown. Correlations with diagnostic studies are uncertain. The lack of precise diagnoses is reflected in a multiplicity of nonspecific treatments, mostly of unproven value. Our current disability-litigation system adds greatly to the problem. Patients are rewarded for nonfunction. Some physicians become advocates for patients, others for insurance carriers and employers. Decisions concerning appropriate treatment are often made by patients, attorneys, the disability determination system, employers, and judges for extraneous reasons, which include financial gain or personal bias and often reflect lack of current information. Even when correct decisions are made, there is a lack of adequate programs for diagnosis and comprehensive treatment of these individuals. The failed back syndrome is not likely to disappear quickly. Large numbers of these patients require care. The best available evaluation includes thorough, but not overly minute investigation using the best current imaging techniques. These studies combined with the history and physical examination should provide a reasonably accurate assessment of the patient’s condition. Concomitant evaluation of psychosocial issues is mandatory, and those who treat these patients without understanding the importance of the various comorbidities discussed are likely to be detrimental. Reparative surgery has real, but limited use. Nerve root compression and instability are the only two conditions demonstrated to be correctable at the present time. However, even when a potentially remediable lesion is found, these patients should undergo a reasonable attempt at physical rehabilitation with attention to both local factors and general function. The best data available today suggest that most of the patients suffering from failed back syndrome are incapacitated by psychiatric, psychologic, and social/vocational factors, which relate to the back complaint only indirectly. Those currently suffering from this problem can be best treated by comprehensive programs that address these complex psychosocial issues. New additions to this category can be reduced by rigorous attention to physical abnormalities, so that surgery is undertaken only for clear indications, and appreciation of the importance of the psychologic aspects of disability from low back pain. The smaller group suffering principally from physical abnormalities can be improved by reparative surgery or pain-relieving procedures if intensive conservative rehabilitation efforts fail. All surgical procedures fail occasionally, and as long as there is a need for reparative surgery, some patients will fail to benefit or be worsened by the procedures.

No doubt insurance companies love it when doctors blame chronic pain on psychological issues, but that negates everything that led up to the problems, including inadequate treatment, treatments that result in even more harm, misdiagnosis, and surgical interventions.

All surgical procedures fail “occasionally”?  I just don’t think that’s true.  But because the medical industry thinks it’s more important to protect itself than the patients it serves, we’ll probably never know just how often surgeries do fail.

This abstract appears to blame everyone except the doctors who send pain patients to surgeons because they don’t know what else to do, along with the surgeons who’s only job it is to cut, regardless of the likely outcome.

More current information doesn’t place as much blame on the patient:

Failed Back Surgery Syndrome (FBSS) refers to a subset of patients who have new or persistent pain after spinal surgery for back or leg pain. The pain can be reduced but still present, or may get worse within a few months after surgery due to a buildup of scar tissue around spinal nerve roots, along with persistent tissue pain and muscle spasm. The term refers to a condition of continuing pain and is not meant to imply there was necessarily a problem during surgery. While published reports estimate the incidence of failed back surgery syndrome to be between 20 – 40%, the likelihood is considered greater with repeated surgery, and the condition will be more prevalent in regions where spinal surgery is more common.

Initial treatment may involve injections, nerve blocks, or a treatment to temporarily block pain signals called radiofrequency neurotomy, which heats up small nerve endings and temporarily blocks the pain. In addition to those pain relief measures, an exercise program to gradually recover muscle strength may also a component of a recovery program.

If the pain is disabling and does not respond to initial measures, neuromodulation treatment may be an option. Electrical neurostimulation can be tried out, in which one or more leads with small electrical contacts are placed near the nerves (such as the spine or the peripheral nerves beyond the spine along the lower back). If pain is reduced during the trial, a small battery, similar to the device used to power a heart pacemaker, is implanted to provide ongoing stimulation.

Large, carefully conducted clinical trials have shown spinal cord stimulation to have superior results, at lower cost, than repeat back surgery for the treatment of FBSS.

Another neuromodulation treatment option is intrathecal drug delivery. Rather than rely on medication taken by mouth, this involves placement of a catheter that delivers pain medication directly to the affected area, requiring less medication and causing fewer side effects.

Reviewed June 11, 2012
Executive Officer, International Neuromodulation Society, 2011-2014
Hunter Pain Clinic, Broadmeadow, NSW Australia

SpineUniverse: When a patient comes to you and their surgery was not successful, what do you do?

Dr. Rashbaum: We find out what went wrong. Typically, the patients I see that clearly have failed back surgery syndrome (FBSS) go back to their doctor, only to find that their doctors are totally disengaged in finding the truth. Unfortunately, this is common.

I’m sorry, I’ve done everything I can; I did it the right way, – by implication they’re alleging they didn’t commit malpractice, and, frankly, most of them haven’t.

I can’t help you, you’ll have to go someplace else, doesn’t help the situation. They don’t arrange for the “someplace else,” and basically what happens is these people become a referral base or repository in chronic pain syndrome in a pain doctor’s clinic.

One of the biggest concerns pertains to whether or not the patient is being subjected to a robust reassessment by the operating surgeon. I’d like to think that they were, but they’re not – at least not uniformly. They’re just sending these people down the road, where the problem could easily be assessed by repeating diagnostic studies like an MRI with gadolinium; an enhancer that helps us ferret out scar tissue from a recurrent disc herniation. You can’t get anywhere if you operate on somebody with scar tissue for leg pain, but you certainly can if they have a recurrent disc herniation…

SpineUniverse: Once you find out what went wrong, what are the next steps?

Dr. Rashbaum:  Sometimes we’ll do injection therapy to help us figure out where the pain is coming from. We need to determine if the pain now is mechanical facet joint pain, mechanical disc degeneration, or painful disc syndrome. Above all, we don’t give up on these patients. We do whatever is needed to reinvestigate, because the important issue with FBSS is that time is of the essence.

SpineUniverse: Do many of these patients need to undergo revision surgery?

Dr. Rashbaum:  What you’re asking is what percentage of FBSS patients could undergo a second surgery and recover with improvement. I hate to say this, but the number of those people that are likely to successfully recover from a second surgery, let alone a third, is not great. Every time you have a re-operation, the likelihood of success diminishes substantially, so by the time you get to the third and fourth surgery, you’re not doing very well. Patients who have failed to benefit from surgery and/or revision surgery and continue to have pain are often good candidates for neuromodulation–spinal cord stimulation…

(2011) Failed back surgery syndrome.

BACKGROUND:  Failed back surgery syndrome (FBSS) is a chronic pain condition that has considerable impact on the patient and health care system. Despite advances in surgical technology, the rates of failed back surgery have not declined. The factors contributing to the development of this entity may occur in the preoperative, intraoperative, and postoperative periods. Due to the severe pain and disability this syndrome may cause, more radical treatments have been utilized. Recent trials have been published that evaluate the efficacy and cost-effectiveness of therapeutic modalities such as spinal cord stimulation for the management of patients with failed back surgery…

Most of the research I’ve read on spinal cord stimulation has been positive — overwhelmingly so. But that doesn’t match the stories of pain patients who have tried this treatment, although I admit I haven’t come across very many of them.  Even though spinal cord stimulation isn’t considered “surgery” by the medical industry, it definitely is, just not as in depth as other surgical treatments.

It appears spinal cord stimulation works for some pain patients, but if you’re in that percentage of patients who suffer complications, you’re in for more pain and suffering. And this invasive treatment doesn’t appear to last very long, but since there are so few options for those suffering from chronic back pain, it’s a treatment that doctors are using more often (even though it’s very expensive).

Just like I’m not interested in trying Lyrica (as Neurontin did not help me at all) or more antidepressants, I’m not interested in trying spinal cord stimulation either (especially after the TENS unit just irritated the hell out of me).  

As often as I request other pain patients to tell me about their experiences, I’ve gotten little feedback.  But that won’t stop me from asking again, so if you have experience with spinal cord stimulation, I would love to hear from you.

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