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Failed back surgery syndrome rates are likely to increase in the future

ByJohn C. Liu, MD

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Spine surgery is a challenging profession. Even though our knowledge of the spine continues to increase with ongoing research, there remains a significant gap in our understanding of how the spine works. Correct diagnosis and meticulous execution of the surgical plan continues to be the hallmark of a successful surgery and satisfied patient. When that falls short, however, failed back surgery syndrome results.

John C. Liu

As noted in this issue’s Cover Story, failed back surgery syndrome (FBSS), sometimes called “post-laminectomy syndrome,” is a generic term used to include any patient who continues to have back or leg pain despite an intended surgery to fix the issue. If we are to reduce the incidences of FBSS, we need to improve our understanding of where and why patients experience pain. Failed back surgery syndrome usually results from either a failure of diagnosis, failure of surgical execution or failure of surgeon judgment. In some patients, there could have been multiple failures along the treatment continuum.

Misdiagnosis of the cause of the patient’s pain, followed by the recommendation of a particular operation for the patient that should not have been done in the first place, remains a major contributing factor to the problem. Until a definitive test can reliably point to the cause of a patient’s back pain or leg pain, proper diagnosis in spine surgery remains a science and an art. Perhaps the “art of spine surgery” should be practiced more often on our patients when the scientific knowledge is simply not there.

Improved diagnostic skills

The lack of a “pain generator scan” dictates the need for us to continue to use our diagnostic skills. These include the physical exam and awareness of the patient’s other social issues, as well as using different imaging modalities, in the quest to obtain the best diagnosis of the patient’s ongoing pain. Sometimes we need to be a social worker and psychiatrist as much as a spine surgeon to really understand patients and the contributing issues that can affect outcomes from any surgeries performed.

Knowing and understanding the spine is critical to make the right diagnosis and offer the correct treatment. As Tyler R. Koski, MD, noted in the Cover Story, the use of radiographs to better understand spinal-pelvic parameters will help avoid iatrogenic causes of additional back pain after surgery. Future improvements in diagnostic abilities with new MRI and imaging modalities may help us better screen patients with real physical pain generators vs. patients with non-physical or more psychologically driven pain.

New research into different patterns of recruitment of core muscles in patients with and without chronic back pain has helped shed light on why certain people tend to have recurrent bouts of back pain. This information can certainly help us better use alternative means of therapy rather than surgery to treat patients and possibly help avoid creating another generation of patients at risk for failed back surgery after unsuccessful — and possibly unnecessary — back surgery.

Better execution of the surgery

Failure of surgical execution is another possible cause of FBSS. Inadequate execution of the operation and intraoperative complications can help create and set in motion changes that may lead to the development of future episodes of back or leg pain. How often do we blame the patient’s unique biology, osteoporosis or smoking habit when a fusion operation did not fuse properly when it may have been due to less than optimal techniques used during surgery? Perhaps we could have done a better job of creating the kind of fusion bed that would maximize the bone biology and fusion process.

Inadequate decompression or failure to address an ongoing structural instability following decompressive surgery remains a common cause of ongoing radicular pain in the cervical and lumbar spine. Our failure to diagnosis this and instead attribute the pain to “scarring” or other causes out of our control places patients in a situation where they must suffer continued pain rather than receiving the treatment they really need. When this occurs, we need to take a more critical look at our surgery and determine if we could have done part of it better. Was the decompression adequate? Did I miss an area of continued stenosis?

Frequently patients with FBSS are told their fusions look great and nothing else can be done for their continued back pain. However, as Christopher L. Shaffrey, MD, FAANS, noted in the Cover Story, the failure to address proper spinal balance is the real reason patients have continued pain. They are told adjacent level disease is an inevitable part of a fusion operation, which may be accurate, but a less than optimal fusion surgery technique created the iatrogenic flat back. The main contributor to the increased rates of failed back fusions is surgeons who fail to undergo continued education, improve their spine knowledge and, in particular, do not pay close attention to the patient’s spinal pelvic alignment.

Practice evidence-based medicine

Failure of surgeon judgment will continue to lead to unsuccessful spine surgeries. Between 1998 and 2008, the number of lumbar fusions increased from 170,000 to more than 400,000. What is driving this rapid increase in the spine fusion rates? At the same time, more new, unproven spine procedures are being performed than ever before, which has led to more patients undergoing procedures that likely may prove ineffective in a few years. It is common to see a promising new spine technique developed and effectively marketed and used by many surgeons, only to find out later it does not work and may have helped generate another group of patients with FBSS.

The enthusiasm for a new procedure often wanes after we learn more of its effects and durability. Such was the case with minimally invasive lateral interbody fusion, which was the rage a few years ago. Once we understood its potential pitfalls, we recommended and now perform these operations with much more scrutiny and caution. The development and introduction of new techniques in the future will, unfortunately, continue to contribute to the increased incidence of FBSS unless surgeons approach them much more carefully before using an unproven technique in patients. It just makes good sense to critically assess all available efficacy data before we use any new device or surgical technique on our patients.

It is interesting to learn deep brain stimulation is being proposed as a possible treatment for central back pain. Although it is as of yet an unproven modality, certainly this is a good example of new, innovative treatments. However, until there is more information available about its efficacy and effects for the spine it should be used with caution. If not, then in the future FBSS could come to stand for “failed brain stimulation surgery.”