Marc Darrow MD,JD

Many people have successful spinal surgery. Some do not. There are many reasons why someone will have a failed spinal surgery. One reason among the many causes can be the muscle damage caused by the fusion surgery itself.

In a situation like this we would examine the spine and look for tenderness and weakness in the muscle attachments / tendons and the spinal ligaments.

If these structures are damaged, we would treat with regenerative injections including platelet rich plasma therapy and/or stem cell therapy.

Surgeons at the Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University in Japan published a paper (1) examining the post-surgical phenomena of back muscle degeneration in lumbar fusion patients. The goal was to find answers for failed back surgery syndrome.

Up to 25% of patients report unimproved or worse pain and up to 40% are not happy with the outcome of lumbar fusion

The Japanese team cited research that suggested:

  • up to 25% of patients report unimproved or worse pain and up to 40% are not happy with the outcome of lumbar fusion.
  • While the researchers acknowledged that there are many possible reasons for poor results, including instrumentation failure, inadequate surgical technique, and poor patient selection, they were looking for the relationship between back muscle injury after surgery and the patient’s chronic back pain.

The relationship was found. In patients who had continued pain after back surgery, muscle biposies revealed:

  • atrophy of paraspinal muscles,
  • loss of muscular support leading to disability and increased biomechanical strain,
  • and possibly failed back syndrome.

“It is well established that posterior spinal surgery results in damage to the paraspinal musculature.”

A team of German and Canadian researchers (2) sought to understand the problem of failed fusion as a result of muscle damage, saying: “It is well established that posterior spinal surgery results in damage to the paraspinal musculature.” The researchers found that axial (mechanical) compressive forces at the adjacent (fusion) levels increased after surgical muscle damage. The results suggest that the paraspinal muscles of the lumbar spine play an important role in adjacent segment loading of a spinal fusion. If the muscles are damaged, adjacent segment disease or failed fusion is more likely.

“27% reduction in muscle density”

Doctors at Oslo University Hospital examined patients who had continued pain 7 to 11 years after spinal fusion.(3) The purpose was to test their observations that reduced muscle strength and density observed at one year after lumbar fusion may deteriorate more in the long term. The results: 27% reduction in muscle density.

In earlier research from Norwegian researchers,(4) patients with chronic low back pain who followed cognitive intervention and exercise programs improved significantly in muscle strength compared with patients who underwent lumbar fusion. In the lumbar fusion group, muscle density decreased significantly at L3–L4 compared with the exercise group.

“muscle and fascia are unexplored pain-generating tissue”

A study from April 2020 (5) went to find the answer of pain after failed back surgery in the soft tissue and muscles of the spine. Lead by the Weill Cornell Center for Comprehensive Spine Care, the study authors “reviewed the pathophysiology and functional aspects of muscle-related back pain. (Through) case presentations (they) demonstrated the utility of evaluation and treatment of sensitized muscles to eliminate pain in failed back surgery patients post-minimally invasive spinal surgery.”

Here is more of what the authors wrote: “In our quest to improve outcomes for minimally invasive spinal surgery, muscle and fascia are unexplored pain-generating tissue. The role of muscle in possibly causing postoperative pain is not simply the effect of sparing of soft tissue. It requires recognizing the possibility that muscle generated pain was a contributing factor presurgically as well as postsurgically and also has effects on muscle function.

The absence of the study of the pathophysiology of muscle pain in medical education impairs the appreciation of the presence of muscle generated pain as an important etiology in assessing surgical candidates.”

Video demonstration of regenerative medicine injections for low back pain

There is no sound on this video. The video demonstrates PRP injection into the lower back. The procedure is well tolerated, simple and in the hands of an experienced physician is a multiple injection treatment given in rapid succession. In our many years of experience, this type of PRP treatment offers the patient reliable and effective results.

There is no sound on this video. The simplicity of the injection treatment is demonstrated. By injecting PRP into the muscles, ligaments, and fascia surrounding the lumbar spine, we can improve the stability of your spine. 

Post-fusion treatment options

At our practice we utilize Platelet-Rich Plasma as one of our injection treatments for the patient with chronic low back pain. We may also utilize bone marrow derived stem cell therapy. The decision as to which one of these treatments to use is based on an examination in the office and an assessment of the person’s pain and functional difficulties along with the patient’s goal of treatment. Someone who needs to return to work as a landscaper will have a different treatment priority than a retired individual with lesser physical demands on his/her back.

PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured or post-surgical areas of the spine to stimulate healing and regeneration. PRP utilizes specific components or your blood, specifically platelets, which act as wound and injury healers. You can read more about PRP and back pain here as well as our stem cell therapy treatments.

In our practice, Stem Cell Therapy is a treatment for musculoskeletal disorders. We treat degenerative joint disease, degenerative disc disease of the spine, and tendon and ligament injury. We offer stem cells drawn from patient’s own bone marrow. Stem cells are “de-differentiated pluripotent” cells, which means that they continue to divide to create more stem cells; these eventually “morph” into the tissue needing repair — for our purposes, collagen, bone, and cartilage.

For the patient suffering from back pain after spinal fusion, nothing about their life is typical except in the common question they ask, “Can your treatments really help me?” There has to be a realistic expectation of what our treatment can do and what they can’t do. If there are issues of continued pain following a fusion surgery, stem cells and PRP treatments may be effective in helping pain if there are issues with ligament and tendon instability causing segment disease above and below the fusion. Stem cells and PRP may help strengthen the tendon/muscle attachments and help patients who suffer from continued spasms.

To make the spinal muscles strong, and build your “core,” you would need resistance training. A problem following fusion surgery is that not only are the muscles damaged, but the muscle tendons are damaged as well. Resistance training or post-surgical rehabilitation cannot be successful if the tendons and muscles are not strong enough to flex and contract enough to build new muscle. Further, the muscle will shrink and atrophy making the spine that much more painful.

Please see my other articles:

Research: Some spinal surgeries and MRIs are unjustified and wasteful

Four case studies of low back pain treated with stem cell therapy

Opioids, Spinal Cord Stimulators, and Failed Back Surgery: Why are people at high risk for failed back surgery still waiting for surgery?

Do you have questions? Ask Dr. Darrow

Marc Darrow, MD. JD., discusses the treatment philosophy of the Darrow Stem Cell Institute. Transcript of video

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

References:

1 Ohtori S, Orita S, Yamauchi K, et al. Classification of Chronic Back Muscle Degeneration after Spinal Surgery and Its Relationship with Low Back Pain. Asian Spine Journal. 2016;10(3):516-521.
2 Malakoutian M, Street J, Wilke HJ, Stavness I, Dvorak M, Fels S, Oxland T. Role of muscle damage on loading at the level adjacent to a lumbar spine fusion: a biomechanical analysis. Eur Spine J. 2016 Sep;25(9):2929-37. doi: 10.1007/s00586-016-4686-y. Epub 2016 Jul 27.
3 Froholdt A, Holm I, Keller A, Gunderson RB, Reikeraas O, Brox JI. No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. Spine J. 2011 Aug;11(8):718-25. doi: 10.1016/j.spinee.2011.06.004. Epub 2011 Aug 3.
4. Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikerås O. Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine (Phila Pa 1976). 2004 Jan 1;29(1):3-8.
5. Marcus NJ, Schmidt FA. Soft Tissue: A Possible Source of Pain Pre and Post Minimally Invasive Spine Surgery. Global Spine Journal. 2020 Apr;10(2_suppl):137S-42S.

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