Failed Back Surgery Syndrome

 

What is failed back surgery syndrome?

Failed back surgery syndrome (FBSS) is interchanged with post laminectomy syndrome.  This is a collaborative term that describes a condition where there is persistent pain despite spine surgery.  It is estimated that 20-40% of patients with spinal fusion will have failed back surgery syndrome.  Despite every effort to reduce complications, even with the best surgeon, one can have unwelcomed surgical "failure".  Patients may find themselves still suffering with back pain and pain down their legs.  

 

Spine surgery is necessary in certain cases to remove any anatomical trigger for pain,  but this is not an “automatic fix” in many cases.  While this is the first step toward the healing process, the importance of post-operative rehabilitation is sometimes overlooked by patients.   After spine surgery, careful follow-up and rehabilitation is very important in order to have a successful outcome.  If there is continued pain after surgery despite adequate time to heal and rehabilitate, then further workup may be warranted to find if there is a new lesion or a different type of problem that could contribute to the patient’s pain.

 

It is important to have a thorough evaluation by a qualified spine specialist like Dr. Faubel who can do a thorough physical exam and determine if there are new neurological symptoms that could be a risk for permanent damage.  In certain cases, it may be necessary to have a second surgery; for example, a recurrent disk herniation, retained disk fragment, compressive hematoma, dural tear, nerve root compression or malposition of hardware or instrumentation failure. Additional testing may be necessary to rule some of the more serious complications.

 

Why is post laminectomy syndrome/ failed back surgery syndrome challenging to treat?

There are many factors that may contribute to persistent pain and there are no typical scenarios; every patient is unique and likewise the treatment plans are individualized.  Recurrent disk herniations may occur at the same level, or adjacent levels may cause recurring radicular symptoms.  With a detailed exam, the specific nerve root level can be identified.  If the nerve root compression is not critical, some patients may be able to achieve relief with Epidural Steroid Injections.  Other causes of nerve root compression may be loose fragments, epidural fibrosis (scarring and fibrous adhesions to the dura), arachnoiditis (intrathecal adhesions and clumping of nerve roots), nerve root cysts or insufficient decompression.  The adjacent levels to a fusion usually have more forces translated through that segment than prior to surgery and these increased forces are also seen at the facet joints which often become symptomatic at a later time.

 

Radiofrequency Ablation is an excellent treatment for facet arthropathy that can provide long term relief.    

 

Cigarette Smoking and Spine Surgical Complications

Pseudoarthosis describes a non-union of the segment intended to be fused.  This creates an unstable fusion.  Patients who are cigarette smokers who fail to stop are at increased risk for pseudoarthosis as well as additional post operative complications such as poor wound healing, increased pulmonary complications, coughing that may exacerbate dural pressures and CSF leaks.  Many surgeons require patients to quit smoking prior to surgery and this will help minimize complications.  Additionally, there are now studies that have shown that smokers experience more pain when compared to non-smokers.  In addition to general health benefits that may be perceived by smoking cessation, wound healing is compromised as well as the immune system and for someone having a major surgery this places them at unnecessary risks of infection. Since there are many possible sources for pain, it is important for patients to help reduce their risk for complications.  With smoking, this is one thing that is in your control; with determination and will power it can done.

 

There may be various treatment options available in order to achieve a reduction in pain associated with post laminectomy syndrome.  Ultimately if all else fails to provide relief, a Spinal Cord Stimulation trial may be recommended.