This articles continues from: Are spinal surgeries as successful as we think? Failed back surgery syndrome.
Previously I had written that I have made it a point throughout this website to display my great admiration for surgeons. I went to medical school to become a surgeon. As I saw more and more failed surgeries I decided to change my practice over to providing non-surgical methods. There are very many people who have had very successful spinal surgeries.
This article will explore some options following failed back surgery.
There is research to suggest that prior to surgery, steps could be taken to help patients avoid risk of a failed back surgery. In the first part of this article I will discuss problems created by treatments prior to surgery that hinders the effectiveness of treatments after failed spinal surgery.
A July 2023 study (1) writes: “Identifying risk factors for the development of adjacent-level syndrome allows the implementation of a prevention strategy in patients undergoing lumbar arthrodesis surgery. Age older than 65 years, high Body Mass Index, preexisting disc degeneration at the adjacent level, and high postoperative pelvic tilt are the most relevant factors. In addition, patients older than 65 years achieve higher levels of clinical improvement and postsurgical satisfaction than do younger patients.”
A July 2023 paper (2) writes that reoperation at L3-L4 for adjacent segment disease (ASD) is common after L4-L5 spine fusion. Researchers of this paper suggest that reducing L4-S1 lower lumbar lordosis (lumbar sway back or over curvature of lumber spine) a common reason for surgery, may in fact lead to an increase in L3-L4 focal lumbar lordosis (one are fixed causing a problem in another) and resulting risk of adjacent segment disease at L3-L4.
Opioids before surgery leads to great risk of failed back surgery syndrome and failure of spinal cord stimulators.
An August 2022 study (1) followed 96 people with chronic low back pain who were on long-term opioid therapy for their back-specific disability and health-related quality of life in patients with chronic low back pain. In surveying the people of this study, the researchers found these patients had worse back-specific disability, physical function, fatigue, limited participation in social settings, and pain interference outcomes. The researchers concluded: “The findings of this study are largely consistent with existing literature regarding the outcomes of long-term opioid therapy. Taken in conjunction with the well-established risks of opioid medications, these findings draw into question the utility of long-term opioid therapy for chronic low back pain.”
A November 2022 paper (2) examined opioid use for chronic pain prior to spinal surgery and the increased rate of post-operative adverse events in these patients. A subgroup of 2,112 patients using opioids preoperatively were followed. The researchers found “significantly higher incidence of infection compared to non-opioid users.”
Many patients choose to have spinal surgery because they do not want to spend a lifetime on painkillers or opioids. As these people wait for their surgery, many find themselves in need of more medications to get them to the surgery. This study from October 2020 (3) demonstrates how improper patient selection can lead to a medical disaster.
In this study, doctors wanted to know why spinal cord stimulation (SCS), while an an effective treatment in failed back surgery syndrome, may not work for everyone. Specifically people who were on opioids prior to the back surgery and the implantation of the spinal cord stimulator following failed back surgery.
- What they found was a higher preimplantation opioid doses associated with unsuccessful spinal cord stimulation suggesting the need for opioid tapering before implantation. With continuous SCS therapy and no explantation or revision due to inadequate pain relief, 39% of failed back surgery syndrome patients discontinued strong opioids, and 23% discontinued all opioids. This indicates that SCS should be considered before detrimental dose escalation.
In the above study the implication is that spinal cord stimulation could help decrease the need of painkillers. A February 2021 study found differently.(4)
A July 2022 paper (5) describes failed back surgery syndrome treatment this way: “Failed back surgery syndrome (FBSS) is associated with persistent lower back pain after and despite one or more surgical interventions. A number of factors underlie and maintain FBSS and successful management of pain chiefly depends on identifying them. Pharmacological, surgical, and non-surgical therapeutic measures are taken to treat the pain. Spinal cord stimulation and nerve stimulation have been widely practiced in this regard and enhanced pain reduction and patient satisfaction. In hernia and recurrent disc degeneration and sagittal imbalance, discectomy and/or fusion are indicated.”
Surgical decompression is recommended in carefully selected patients who do not improve after nonsurgical care. The use of additional fusion in surgery for degenerative spondylolisthesis has been a controversial issue. Arguments for fusion have included the assumption that pain arises from abnormal movement in the slipped segment and that this problem might worsen after decompression. In the past 3 decades, decompression with fusion has been the gold standard for treatment of patients with spinal stenosis with spondylolisthesis as well as for many patients without spondylolisthesis. However, current evidence indicates that the more invasive fusion procedure is associated with increased costs but not clinical benefits
Conservative care treatments
Pharmaceutical
A May 2022 update in STATPEARLS, (6) a book of the National Library of Medicine writes: “Studies of conservative treatment specifically for failed back surgery syndrome are rare, and the studies that do exist are often contradictory. Common pharmacologic treatments include non-steroidal anti-inflammatory drugs (NSAIDs), opioids, anticonvulsants, and antidepressants. NSAIDs are commonly prescribed drugs for many different etiologies of lower back pain, for which they have been shown to have an advantage over placebo. While opioids are commonly used to treat chronic pain, evidence for their use in FBSS is generally weak, and the risk of dependence and resultant substance use disorder must be strong consideration before their use.
Because there was little long-term data on Spinal cord stimulation in helping patients with failed back surgery syndrome, doctors conducted patient reviews in people who had spinal cord stimulation devices, some for 20 years or more. In this May 2022 study (7), researchers looked at overall patient satisfaction, pain intensity, and adverse events for 191 patients who received a permanent SCS implant. Secondary health measures included the influence of opioid and nicotine use on pain reduction after therapy.
- 78.5% of the patients were satisfied with the treatment outcome, with a significant pain reduction of an average three points on a Numeric Rating Scale (0-10).
- Opioid and nicotine usage did not have a significant link with the pain reduction one year after the treatment.
- Devices had an average battery lifespan of 8.4 years. A total of 248 revisions were recorded. A total of 24 patients (11.7%) acquired an infection; 7 of 204 patients had an infection during the trial period, 2 of 191 patients had an infection in the first postoperative year, and 15 of 191 patients had an infection after the first year. The average time to infection, if not in the first year, was 10.1 years.
Conclusions: “A successful long-term outcome regarding pain relief in patients with predominant radicular pain due to FBSS is established with SCS therapy.”
In this paper doctors at John Hopkins University wrote:
“Spinal cord stimulation (SCS) has been considered as an alternative therapy to reduce opioid requirements in certain chronic pain disorders. However, information on long-term opioid consumption patterns and their impact on Spinal cord stimulation device explantation is lacking.
(The researchers) conducted a retrospective study of 45 patients to characterize long-term patterns of opioid usage after Spinal cord stimulation implantation.
Results:
- Daily morphine equivalent dosage increased in 40% of patients
- Daily morphine equivalent dosage decreased in 40% of patients
- and 20% of patients used the same amount of pain medications at 1-year follow-up
Spinal cord stimulation removed because of failure – when the spinal cord stimulators were removed – pain medication usage dropped in some patients
- Twelve (27%) underwent explantation due to treatment failure at a median of 18 months after implantation.
- Following explantation, reduction in the daily medication was seen in 92% of patients with dosages falling below pre-operative baseline in nine.
- (The) results indicate that daily opioid consumption does not decrease in most patients one-year after Spinal cord stimulation implantation.
Anterior view X-ray of a Medtronic Spinal Cord Stimulator (SCS) with 5-6-5 paddle lead implanted in the posterior epidural space of the thoracic spine. Image used in compliance with Wikimedia Commons attribution: Mconnell, CC BY 3.0, via Wikimedia Commons
Research demonstrates that current SCS technology does not reliably help a larger number of patients reduce opioid usage
A January 2020 report in the journal Neuromodulation (5) agrees:
“With only half of chronic opioid users demonstrating meaningful opioid reduction after SCS implantation, we demonstrate that current SCS technology does not reliably help a larger number of patients reduce opioid usage. Women, older age, and preoperative MED (pain medication usage) are predictive of meaningful opioid reduction but only one of these is modifiable. As not all patients saw benefit from their therapies, there is still much room for improvement in the treatment of refractory chronic pain that is associated with failed back surgery syndrome and chronic regional pain syndrome.”
But at 10 years of spinal cord stimulation, 78% of patients were satisfied with pain relief after failed back surgery
A May 2022 study (6) examined long-term spinal cord stimulation in patients with failed back surgery. At an average follow-up of 10.6 years, 78.5% of the patients were satisfied with the treatment outcome. On the Numeric Rating Scale (0-10, 10 being worst pain) patients reported a significant pain reduction of an average three points. The authors concluded: “A successful long-term outcome regarding pain relief in patients with predominant radicular pain due to failed back surgery syndrome is established with SCS therapy.”
Lumbar sympathetic ganglion block
A January 2023 study (11) compared pain and quality of life in patients with failed back surgery syndrome who responded and did not respond to Lumbar sympathetic ganglion block. Lumbar sympathetic ganglion block reduced pain at all-time points. Patients who showed more than 50% reduction in pain at one week had improved quality of life simultaneously. However, patients who showed less than 50% reduction in pain at one week had no improvement in quality of life. Lumbar sympathetic ganglion block did not influence the coldness of the leg.
When someone asks about bone marrow stem cell therapy for failed back surgery, what do we answer?
We will get many emails from people suffering from back pain after numerous spinal surgeries. They ask one of two questions. First: “Can stem cells really help me?” Second: “Is there any research that stem cells can help me?”
There is not much by way of research on any conservative care options much less stem cell therapy. This is pointed out in a May 2021 updated in the medical publication Stat Pearls (7) :
“Therapies for the treatment of failed back surgery syndrome broadly split into conservative (physical therapy or medication) and aggressive (interventional or surgical) management. Conservative management should always be the first option before invasive techniques in patients without indications for emergency surgery.
Studies of conservative treatment specifically for failed back surgery syndrome are rare, and the studies that do exist are often contradictory. Common pharmacologic treatments include non-steroidal anti-inflammatory drugs (NSAIDs), opioids, anticonvulsants, and antidepressants. NSAIDs are commonly prescribed drugs for many different etiologies of lower back pain, for which they have been shown to have an advantage over placebo. While opioids are commonly used to treat chronic pain, evidence for their use in failed back surgery syndrome is generally weak, and the risk of dependence and resultant substance use disorder must be strong consideration before their use. As such these should be considered a treatment of last resort and undertaken in a multidisciplinary program. Small trials using anticonvulsants such as gabapentinoids or antidepressants in FBSS therapy have shown promising initial results, but long-term efficacy is undetermined.”
They key to this 2021 updated on failed back surgery is that the little research there is, does not include much on stem cell therapy.
There has to be a realistic expectation of what stem cells can do and what they can’t do. If there are issues of continued pain following a fusion surgery, stem cells may be effective in helping pain if there are issues with ligament and tendon instability causing segmental disease above and below the fusion. Stem cells may help strengthen the tendon/muscle attachments and help patients who suffer from continued spasms. In situations where a laminectomy was performed, we would certainly explore the spinal ligaments as a possible cause of instability and pain.
References:
1 Cannizzaro D, Anania CD, De Robertis M, Pizzi A, Gionso M, Ballabio C, Ubezio MC, Frigerio GM, Battaglia M, Morenghi E, Capo G. The lumbar adjacent-level syndrome: analysis of clinical, radiological, and surgical parameters in a large single-center series. Journal of Neurosurgery: Spine. 2023 Jul 14;1(aop):1-1.
1 Schultz MJ, Licciardone JC. The effect of long-term opioid use on back-specific disability and health-related quality of life in patients with chronic low back pain. Journal of Osteopathic Medicine. 2022 Aug 11.
2 Gonzalez GA, Corso K, Miao J, Rajappan SK, Porto G, Anandan M, O’Leary M, Wainwright J, Smit R, Hines K, Franco D. Does pre-operative opiate choice increase risk of post-operative infection and subsequent surgery?. World Neurosurgery. 2022 Nov 14.
3 Nissen M, Ikäheimo TM, Huttunen J, Leinonen V, Jyrkkänen HK, von und zu Fraunberg M. Higher Preimplantation Opioid Doses Associated With Long‐Term Spinal Cord Stimulation Failure in 211 Patients With Failed Back Surgery Syndrome. Neuromodulation: Technology at the Neural Interface.
4 Hwang BY, Negoita S, Duy PQ, Tesay Y, Anderson WS. Opioid use and spinal cord stimulation therapy: the long game. Journal of Clinical Neuroscience. 2021 Feb 1;84:50-2.
5 Alizadeh R, Sharifzadeh SR. Pathogenesis, etiology and treatment of failed back surgery syndrome. Neurochirurgie. 2021 Sep 17.
6 Orhurhu VJ, Chu R, Gill J. Failed Back Surgery Syndrome. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
7 Puylaert M, Nijs L, Buyse K, Vissers K, Vanelderen P, Nagels M, Daenekindt T, Weyns F, Mesotten D, Van Zundert J, Van Boxem K. Long-Term Outcome in Patients With Spinal Cord Stimulation for Failed Back Surgery Syndrome: A 20-Year Audit of a Single Center. Neuromodulation: Technology at the Neural Interface. 2022 May 14.
8 Dougherty MC, Woodroffe RW, Wilson S, Gillies GT, Howard III MA, Carnahan RM. Predictors of reduced opioid use with spinal cord stimulation in patients with chronic opioid use. Neuromodulation: Technology at the Neural Interface. 2020 Jan;23(1):126-32.
9 Puylaert M, Nijs L, Buyse K, Vissers K, Vanelderen P, Nagels M, Daenekindt T, Weyns F, Mesotten D, Van Zundert J, Van Boxem K. Long-Term Outcome in Patients With Spinal Cord Stimulation for Failed Back Surgery Syndrome: A 20-Year Audit of a Single Center. Neuromodulation: Technology at the Neural Interface. 2022 May 14.
10 Orhurhu VJ, Chu R, Gill J. Failed Back Surgery Syndrome. [Updated 2021 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539777/
11 Lee JY, Sim WS, Kim J, Yang S, Ro H, Kim CJ, Kim SU, Park HJ. The analgesic effect of lumbar sympathetic ganglion block in patients with failed back surgery syndrome. Frontiers in Medicine. 2022;9.