Failed back surgery syndrome

Dr. Moradi, a neurologist

Failed back surgery syndrome occurs when back pain persists after spine surgery—beyond normal post-surgery pain while recovering. Instead, the surgery did not provide the expected results or, in fact, created additional back pain.Treatment for failed back surgery syndrome may include physical therapy, nerve blocks, medications, injections or surgery.

Causes of Chronic Post-Surgical Spinal Pain

Spinal pain that occurs right after surgery is from sensitized nerves, while chronic post-surgical spinal pain is often from spinal instability but can have many different causes.

  • Surgery caused arachoiditous:a condition of acute inflammation of the arachnoid membrane that surrounds and protects the nerves of the spinal cord. Symptoms include intense burning or stinging pain and neurological problems.
  • Deconditioning: too much bed rest
  • Enthesopothy: The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone. The term enthesopathy typically refers to a degenerated enthesis; though when some doctors use this term, they typically mean enthesitis (inflammation of the enthesis).
  • Epidural Fibrosis (scar tissue)
  • Failure of the fusion, This is the failure of the bone and hardware to graft
  • Neuralgia- Nerve pain: To perfrom a surgical procedure, many superficial sensory nerves have to be cut in order to get down to the vertebrae, and sometimes these nerves get inflamed and/or compressed as they rebuild themselves.
  • Spinal Instability
    • The surgery caused spinal instability by removing too much bone.
    • The surgery caused spinal instability by damaging the spinal ligaments.

Failed Back Surgery Syndrome Symptoms 

A number of symptoms may unfold with failed back surgery syndrome:

  • New persistent back pain after surgery, in the back, neck or extremities
  • Restricted mobility related to the spine
  • Failure to recover
  • Additional spine conditions

Spinal surgery recovery does take significant time and since many of these symptoms occur with many other spine conditions, having a spine specialist with a wide-range of experience can more accurately diagnose what the origination of your back pain is.

Diagnose Failed Back Surgery Syndrome

Physical Examination 

Your doctor performs a physical exam to determine and evaluate the source of back pain. He or she may look for restricted movement in the spine or neck and weakness in the arms or legs. You may be asked to walk or bend, so that your doctor can view your spine in motion.During the physical exam, your doctor may perform a neurological evaluation to determine if nerve damage is causing your symptoms. These painless tests may involve using a small hammer to test parts of your body for unresponsive nerve reflexes, which can indicate a pinched nerve.The doctor may also expose the skin to stimuli, such as a cold metal instrument, to determine if sensation is affected. To assess weakness, which can be caused by nerve compression, your doctor may ask you to move certain muscle groups or push back when he or she puts pressure on your muscles.

X-rays and EOS Imaging 

Doctors often first recommend X-rays, which are two-dimensional images of the inside of the body.A newer technique called EOS® imaging is a type of X-ray that creates three-dimensional pictures of the entire body, including the spine and nearby soft tissue. It can help determine if a malalignment of your spine is a contributing factor to continued pain and disability.

MRI Scans

Your doctor may recommend an MRI scan, which uses a magnetic field and radio waves to create detailed images of the ligaments, discs, and soft tissue of the spine. This test provides clearer images of soft tissue than a CT scan.MRI scans can identify bulging or slipped discs, which occur when the inner part of a disc protrudes through the outer rings of the disc—often due to injury or weakness—causing back pain.

CT Scans 

A CT scan—which uses X-rays to create cross-sectional, three-dimensional images of the spine—can provide better images of bones than an MRI. It may be used to identify bone spurs, which are growths that can develop on spinal bones, and to determine if you have any fractured bones or displaced vertebrae.

Bone Scans 

Sometimes a bone scan is performed to identify changes in bone, such as fractures in the spine. This helps the doctor to determine if a new injury is the cause of your symptoms.In this test, the doctor injects a substance called a tracer into a vein in the arm. The tracer travels through the blood to the bones, where it collects in areas with changes called “hot spots.” This can help the doctor to identify fractures that aren’t visible on X-rays.

non-surgical methods for Failed back surgery syndrome

some common non-surgical methods for treating back pain after surgery include;

Medication

Take an over-the-counter (OTC) pain reliever. Nonsteroidal anti-inflammatory (NSAID) medications can help reduce pain and inflammation. Common OTC NSAIDs include ibuprofen (Advil, Motrin) and naproxen (Aleve).You may also get relief from acetaminophen (Tylenol). While it does not have anti-inflammatory properties, it has a smaller chance of upsetting your stomach.You can also try a muscle relaxant. Use the smallest dose possible, as these can cause drowsiness.

Corticosteroid Injections

If NSAIDs don’t relieve back pain, your doctor may recommend an injection of corticosteroids, which reduce inflammation, and a local anesthetic, which reduces pain, into the spinal canal. In some people, the injection can alleviate pain for weeks, months, or even years. However, there is no reliable method for predicting the effectiveness of this treatment.You can expect to return home immediately after the injection. You may feel slight tenderness at the injection site for a day or two. Doctors typically recommend limiting spinal injections to no more than two or three per year.

Nerve Block Injections

In a nerve block, a doctor injects the area around the nerve with a numbing medicine, or anesthetic. Lidocaine is the anesthetic most commonly used.After a nerve block injection, you’ll quickly have numbness with near-complete pain relief. It wears off after several hours.

Facet Thermal Ablation

Thermal ablation uses a laser, guided through a one-inch incision, to deaden the nerves that are being compressed at the facet joints that are responsible for bending and twisting motions. Because the targeted nerves feed only the facet joints, this procedure will not affect your ability to feel or move freely; instead, it will deaden the pain signal from the affected area to your brain and open up compressed areas.The laser and instruments used to remove excess bone, are fed through a slim tube. The tissue around it is expanded, rather than cut, so post-operative pain is minimal and healing is rapid for most people.This approach is at the heart of the minimally invasive, muscle-sparing approach that we use at Physician Partners of America.Facet thermal ablation is similar to radio frequency ablation. Both are minimally invasive procedures that target a specific area of the spine’s facet joints. Here’s the difference: RFA uses heat to stun the affected nerve for a few months or years, while a laser deadens it permanently.

Radiofrequency Nerve Ablation

The procedure can be done under IV sedation or using local anesthesia. After the area is numbed, the surgeon uses live X-ray t guide him or her to the affected medial or lateral branch nerves. A tiny electrical current is passed through a needle to the targeted nerve to ensure precision. It may cause brief discomfort and muscle twitching. Radio frequency waves heat the tip of the needle to create a heat lesion in the affected nerve. This disrupts its ability to send pain signals to the brain.Most people tolerate RFA well, and it has few complications. Common side-effects of bruising and swelling generally go away after a few days. The procedure has a 70 percent success rate. Its effects can last up to a year, but some people see some degree of pain relief for several years.

Surgery

Foraminotomy 

A foraminotomy involves carefully removing sections of tissue or bone that are pressing on the foraminal nerve. Once the pressure is relieved, the pain subsides.Foraminotomy may be used in conjunction with other procedures such as a laminotomy or laminectomy.The lamina is a small, bony plate that surrounds the spinal canal. Removing all or part of it makes it easier to access the foraminal nerve.Your surgeon will use an MRI to pinpoint the nerve root that is being compressed. A small incision, no larger than a Band-Aid, is made at the site. Tubular retractors are used to hold tissue and muscle away from the spine during the procedure, as opposed to the cutting needed for traditional open back surgery.Minimally invasive surgical procedures like foraminotomy are usually a last resort treatment for these pain conditions. You and your surgeon will decide together whether you are a candidate for this type of treatment.

Spinal Fusion

Surgeons may perform a spinal fusion—in which unstable vertebrae are permanently joined together—to correct a painful misalignment or overalignment of the spine caused by failed back surgery.In this procedure, the surgeon makes an incision in the middle of the back and uses a special tool to separate skin, muscle, tissue, and blood vessels. Next, he or she uses metal screws and rods to hold, or fuse, the bones together and keep them in the correct position.The doctor may also place a small piece of bone between the vertebrae to provide additional stability. This piece of bone, which is called a graft, can be from your own body—typically taken from the hip—or from a donor. The graft may be placed directly between the vertebrae or inside a small, thimble-like metal device that is placed between vertebrae.As the joined vertebrae heal, they fuse into one bone mass, providing stability and reducing pain by removing pressure on nerve roots or the spinal cord that was caused by the poorly aligned spine.During a spinal fusion, the surgeon may also widen the foramen, the opening in the spine where the facet joints fit together. He or she may also trim protruding facet joints or remove herniated, or bulging, discs or bone spurs. These procedures can reduce pain by creating more space in the spinal canal and decompressing impinged nerves.

microdiscectomy 

The incision is only 1 to 1.5 inches. Guided by fluoroscopy, or live X-rays, the surgeon uses a special microscope outfitted with a camera and small, specialized instruments. Small tube-like retractors pull the surrounding tissue and muscle apart instead of cutting them. Before the disc material is removed, the surgeon may widen the opening of a bone called the lamina from the affected vertebra. This, process, called laminectomy, helps the surgeon see the herniated disc more clearly through the camera.This type of procedure is minimally invasive and muscle-sparing, meaning healing time is shorter and post-operative pain are much more tolerable than is the case in traditional open-back surgery.Many patients feel improvement immediately upon waking up from surgery and are able to resume work and daily activities soon afterward.