Failed back surgery syndrome [FBSS, or failed back syndrome] is a vague term used to describe the condition of patients who did not get a successful result with back surgery and have experience continued pain.
A spine surgery in lumber region is mainly done for two causes
- To decompress a nerve root
- To stabilize a painful joint.
Failed back surgery syndrome is a group of disorders with persistent or recurrent symptoms following spinal surgery with hallmarks of back pain, sciatica and functional impairment. The severity of failed back surgery is often sufficiently great to cause a change in the job.
Presentation
The diagnosis of a failed back is often a clinical challenge.There is a history of one or more back surgeries. Common symptoms associated with failed back surgery syndrome include diffuse, dull and aching pain involving the back and/or legs. Abnormal sensibility may include sharp, pricking, and stabbing pain in the extremities.
Xray, conttrast enhanced CT, MRI, aid in diagnosis. Out of these MRI has got the best sensitivity and accuracy.
What Are The Procedures Done That may Result In FBSS
- Laminotomy
- Discectomy or Diskectomy
- Spinal Fusion
Role of Patient Selection
Patients who have pain radiating down the buttock to the leg and have an identifiable radicular nerve loss will have a better post operative course that those who simply have low back pain.
If a specific disc herniation causing pressure on a nerve root cannot be identified, the results of surgery are likely to be disappointing.
Moreover, patients involved in worker’s compensation, tort litigation or other compensation systems tend to fare more poorly after surgery.
Oaklander and North define the Failed Back Syndrome as a chronic pain patient after one or more surgical procedure to the spine. They delineated these characteristics of the relation between the patient and the surgeon:
- The patient makes increasing demands on the surgeon for pain relief.
- The patient grows increasingly angry at the failure and may become litigious.
- There is an escalation of narcotic pain medication which is habituating or addictive.
- In the face of expensive conservative treatments which are likely to fail, the surgeon is persuaded to attempt further surgery, even though this is likely to fail as well.
- The probability of returning to gainful employment decreases with increasing length of disability.
- The financial incentives to remain disabled far outweigh the incentive to recover.
In the absence of a compensation, other psychological features may limit the ability of the patient to recover from surgery.
Causes Of Failed Back
Most common cause of failed back is selecting wrong patient for surgery. Apart from this the other causes that may lead to failure of surgery are -
Persistent or Recurrent Disc Herniation
Removal of a disc at one level can lead to disc herniation at the same level or a different level at a later time. Even the most complete surgical excision of the disc still leaves 30-40% of the disc, which cannot be safely removed. This retained disc can re-herniate sometime after surgery. Most common cause of a failed back syndrome is caused from recurrent disc herniation at the same level originally operated. A rapid removal in a second surgery can be curative.
Spinal stenosis can be a late complication and is thought to be a significant cause of failed back.
Post operative infection
A small minority of lumbar surgical patients will develop a post operative infection. In most cases, this is a bad complication with incidence from 0-12%. The incidence of infection tends to increase as the complexity of the procedure and operating time increase. Usage of metal implants tends to increase the risk of infection.
Factors associated with an increased infection include diabetes mellitus, obesity, malnutrition, smoking, previous infection, rheumatoid arthritis, and immunodeficiency. Previous wound infection should be considered as a contraindication to any further spinal surgery
Epidural Scar
Epidural scarring may occur following repeated surgeries.
Arachnoiditis
Arachnoiditis is a means inflammation of the meninges and subarachnoid space.The most common cause of arachnoiditis in failed back syndrome is due to non-specific scarring secondary to the surgery or the underlying pathology.
Nerve injury
Laceration of a nerve root, or damage from cautery or traction can lead to chronic pain
Treatment
There is no definitive treatment for this problem.
The treatments used are
- Physical therapy
- Nerve blocks
- Transcutaneous electrical nerve stimulation (TENS)
- Behavioral medicine
- Non-steroidal anti-inflammatory (NSAID) medications,
- Membrane stabilizing drugs
- Antidepressants
- Spinal cord stimulation
- Intracathecal morphine pump
- Epidural steroid injections
The targeted anatomic use of a potent anti-inflammatory anti-TNF therapeutics is being investigated. Sometimes a repeat surgery may help if definitive offending structure/cause is identifiable.
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