Marc Darrow, MD, JD.
In this article I hope to share with you three main thoughts from recent research.
- Who is at risk for failed back surgery?
- What happens to put people at risk for failed back surgery syndrome before the surgery?
- What can be done in situations for failed back surgery syndrome after the surgery?
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.
We receive many emails from patients who have undergone numerous spinal procedures. These people are in continued pain and are looking for help. Because of the complexities of spinal surgery, especially in patients with numerous procedures, this question, “can stem cell therapy help me with my failed back surgery diagnosis?” must be answered following a physical examination and consultation where realistic healing options can be discussed. We are going to discuss stem cell therapy in the treatment section of this article.
Many people who have had a failed back surgery do not jump right back into another surgery. Many jump back into the conservative care loop that sent them to spinal surgery in the first place. Following failed back surgery the patient may be sent to physical therapy, get epidural steroid injections, get cortisone injections, be prescribed stronger painkillers and anti-inflammatory medications before they are told that another surgery may be needed. When a person contacts our office looking for options to a second or even third spinal procedure we do want to help them pursue a non-surgical path. Research has made it clear the more surgeries, the worse off the patient is. This was also made clear to them by their own surgeons who warned them that the revision surgery they have planned may not work either and may make them even worse. Let’s explore the research in support of that statement.
“The need for revision surgery declined but not because the first surgery was successful but because the second procedure was thought too risky”
The success of spinal surgeries is seen by some as a decrease in the need to have a second surgery. A second surgery implies in some patients that their first surgery has somehow failed. Recent research published in the Journal of Bone and Joint Surgery (1) looked at the reasons and likelihood that a patient would need a second spinal surgery for stenosis. One thing that they noted was that the need for revision surgery declined but not because the first surgery was successful but because the second procedure was thought too risky.
In another recent study (2) surgeons discussed treatment options for Failed Back Surgery Syndrome patients. One thing they discussed was in many cases revision or repair surgery were not viable options. They wrote:
“A significant number of lumbar post-surgical patients continue to suffer persistent pain and limited function and are termed to have “Failed back surgery syndrome” (FBSS). Treatments for FBSS may be generally categorized as physical therapy and exercise, medications, neuromodulation and re-operation. . . Evidence is weak for medications and re-operation, but strong for active exercise and interventional procedures such as adhesiolysis. (Surgery to removal scar tissue that resulted from the initial surgery).” Evidence remains week that surgery can fix a failed back surgery.
Older patients opting out of second surgery.
When I was in medical school, I did surgical research and assisted in the operating room much more than my classmates. By the time I had finished medical school and internship (where I spent as much time as possible doing orthopedic procedures) I had seen too many surgical failures including my own shoulder surgery. Worse was when the first surgery clearly failed, the patient was offered a second surgery to fix the first one. Older patients usually refused the second surgery, later documented in the research: “The likelihood of repeat surgery for spinal stenosis declined with increasing age and other diseases, perhaps because of concern for greater risks.” (3) There may have been less surgeries because older patients were not able to have them.
In April 2020, a study titled: “The Long-Term Reoperation Rate Following Surgery for Lumbar Stenosis,” found these statistics for lumbar stenosis surgery:(4)
- The overall cumulative incidence of reoperation for lumbar stenosis was:
- 6.2% at 2 years,
- 10.8% at 5 years and
- 18.4% at 10 years.
- The overall cumulative incidence of reoperation for anterior fusion was 20.6% at ten years post-op.
- The overall cumulative incidence of reoperation for posterior fusion was 12.6% at ten years post-op.
- The overall cumulative incidence of reoperation for decompression was 18.6% at ten years post-op.
Which patients are at higher risk for failed back surgery syndrome?
A September 2022 paper (5) looked at the surgical outcomes of over 100,000 spinal surgery patients. This is what they found as it relates to a failed back surgery classification.
Results:
- Of 102,047 patients who had lumbar fusion or decompression surgery (54% decompression procedures, 36% posterior fusions, and 8.9% anterior fusions) 5.4% of patients were diagnosed with failed back surgery syndrome within six months of the procedure, and 8.4% were diagnosed with failed back surgery syndrome within twelve months.
- High rates of failed back surgery syndrome occurred in in the elderly (age group 70-74).
- Among the surgical techniques, multi-level procedures had significantly higher rates of failed back surgery syndrome than single-level procedures, the highest being 10% in multi-level inpatient decompression procedures.
The general numbers of this study are that out 1 in 20 patients will develop failed back surgery in the first six months post-operation. This number will rise to about 1 in 12 within the first year of the surgery. Why are these numbers that high? Research suggests it is because inappropriate patients are getting surgery. Let’s follow that up.
An August 2022 paper (6) suggested: “The most common reasons for early reoperation (revision surgery within three months) and late operation (revision surgery after 3 months) were surgical site infection and adjacent segment diseases, respectively. Osteoporosis and diabetes were independent risk factors for early reoperation, and multilevel fusion was independent risk factor for late reoperation. Surgeons should pay more attention to these patients, and future studies should consider the effects of follow-up periods on results.”
Surgeons tell their fellow surgeons to warn their patients that their spinal surgery will probably not help them as much as the patients may wish it would.
As we see in the above research, up to 1 out of 12 patients will have failed back surgery syndrome within one year of the surgery. There are many more patients whose outcomes did not meet their expectations.
In a 2018 study from the Netherlands (7), surgeons recommended that doctors do not refer many patients to spinal surgery who:
- Suffered from a degree of disability,
- already had 2 or more previous spine surgeries,
- psychosocial complaints, (the feeling of being unneeded, unwanted or burdensome)
- or if the patients were over 50, because the likelihood for the majority of them is that the surgery will not be helpful.
The theme here is the appropriateness of the patient. Patients who were not good candidates for surgery and have the surgery are at higher risk for the surgery failing. This is further outlined in an April 2022 paper (8) where patients who received a second opinion and were still recommended to surgery had better outcomes. In this study of 100 patients, 88 had a lumbar decompression, 12 had a lumbar fusion. Of interest is that between the first and second opinions, the two doctors agreed on what the diagnosis was only 44% of the time. Between the first opinion doctor and the second opinion doctor, only 27 agreed on a treatment recommendation. This study concludes: “the high rates of diagnostic and therapeutic indication disagreements corroborate the need of a second opinion in cases of spine disease with surgical indications.”
A January 2024 study (9) noted “over 60.0% of patients with low back pain (are) being referred to spine surgeons without any surgical indication. . . (this reveals) a significant proportion of inappropriate referrals to specialized care for low back pain.”
In this paper, 500 patient cases were analyzed, only 112 (22.4%) were surgical candidates, while 221 (44.2%) were discharge from the neurosurgery service upon initial assessment. . . . “over 80.0% of referrals made during the study period were deemed inappropriate. Inappropriate referrals were characterized by higher proportion of patients symptomatically improved, presenting a back-dominant chief complaint, exhibiting no objective neurological symptoms, and diagnosed with non-specific low back pain.”
Improvement in pain was the major expectation of patients undergoing lumbar spine surgery. For many, this was not achieved.
In a recent study, doctors at Weill Cornell Medical College in New York and the Hospital for Special Surgery, (10) discussed with patients what their pre-surgery expectations were and their satisfaction after the surgery. In other words, “how did the surgery turnout?”
The average age of this patient group was was 56 years old and 55% were men. Improvement in pain was the major expectation of patients undergoing lumbar spine surgery.
- Two years after surgery 11% of patients reported no improvement in pain, (1 out of 9)
- 28% reported a little to moderate improvement, (more than 1 out of 4)
- In total from first two groups 40 % of the patients report no, little or moderate pain relief
- 44% reported a lot of improvement,
- and 17% reported complete improvement.
This same warning is echoed in a recent study in the journal Pain Practice: (11) The patient-physician encounter forms the cornerstone of every health service. However, optimal medical outcomes are often confounded by inadequate patient-physician communication. Therefore, it is crucial to address all components of the patient’s pain experience, including beliefs and expectations.
Are spinal surgeries as successful as we think? Factors before surgery that lead to risk of spine surgery failure
A December 2020 (12) study included 647 patients who had undergone lumbar spine surgery. Of these, 564 (87%) indicated that they were satisfied with the care they received. But did this translate to a better situation for the patient? One aspect that the researchers questioned was how pain was reported. In fact, how patients reported their pain may lead to skewed satisfaction scoring. The study notes: “pain-related outcome measures may serve as better predictors of patients’ satisfaction with their spine surgeons. Furthermore, this suggests that the current method by which patient satisfaction is being assessed and publicly reported may not necessarily correlate with validated measures that are used within the spine surgery setting to assess surgical efficacy.
A February 2023 study (13) explored why some patients had a failed lumbar decompression surgery with and without fusion. In this study of nearly 9000 patients, researchers found “After surgery for lumbar spinal stenosis, 33% of the patients reported failure, and 22% reported worsening . . . Preoperative duration of back pain for longer than 12 months, former spinal surgery, and age above 70 years were the strongest predictors for increased odds of failure and worsening after surgery.”
A group of Canadian doctors wrote in a July 2022 study (14) of the “complex relationship” between a patient’s pre-operative expectations of their spinal surgery, if those pre-surgery expectations were met, post-surgical outcomes, and satisfaction after spine surgery to help determine, what is a successful spinal surgery.
This study was conducted as a Canadian national study of patients undergoing elective surgery for degenerative spinal conditions
- Fifty-eight percent of patients were extremely satisfied, and 3% were extremely dissatisfied.
- Pre-surgery outcome expectations were variable and generally high.
- 17.3% of patients reported that none of their expectations were met.
- 49.8% reported that their most important expectation in the majority disability or pain improvement was met.
- 32.9% reported that their most important expectation was not met but others were.
The study further noted: “A large proportion of patients reported unfulfilled expectations of outcomes secondary to spine surgery, such as improvements in mental well-being. This may reflect unrealistic expectations that are ultimately unattainable and leading to patients’ dissatisfaction with surgery. It has also been shown that there is a large discrepancy between surgeons’ and patients’ expectation across different expectation dimensions.” However, “Despite this disparity, most patients (85%) were satisfied with the results of the surgery.”
An August 2022 study (15) investigated whether surgery met the patient’s preoperative expectations for back or leg pain or the achievement of minimum clinically important difference (MCID) on patient satisfaction following lumbar fusion.
- A total of 134 patients were included in this study. Patients demonstrated significant improvements in VAS back (0 – 10 pain scores) back and VAS leg (back and leg pain scores 0 – 10).
- At one year, 56.4% of patients had their VAS back expectations met compared with 59.5% for VAS leg.
- Similarly, at one year, 77.3% and 71.3% of patients achieved minimum clinically important difference for VAS back and leg, respectively.
Failure to return to work and physical activity is one aspect
This was also alluded to in an October 2020 paper (16) which wrote: “Studies have found that most patients are satisfied after spine surgery, with rates ranging from 53% to 90%. Patient satisfaction appears to be closely related to achieving clinical improvement in pain and disability after surgery. While the majority of the literature has focused on patients who report both satisfaction and clinical improvement in disability and pain, there remains an important subpopulation of patients who have clinically relevant improvement but report being dissatisfied with surgery.” The researchers then asked why were the patient’s dissatisfied? They found: “Several modifiable factors, including psychological distress, current smoking status, and failure to return to work and physical activity, helped explain why patients report being dissatisfied with surgery despite clinical improvement in disability or pain.”
The more surgeries the worse off the patient
In the research above, recommendation is given that patients who already had 2 or more previous spine surgeries had a high risk of failed back surgery syndrome recurring and worsening.
Some people will get benefit eventually from surgery. Some will not. Doctors, including those from the University of Bern in Switzerland published their research findings (17) on patients who had to undergo multiple spinal surgeries. When they examined patients 12 months after their last surgery they found that the more surgeries a patient had, the less likely they would have clinical success.
The Swiss doctors warned that when suggesting to patients further spinal surgeries, the patients needed to be advised that the outcome may not be good and that they, the patient, should set realistic expectations so as not to be discouraged by poor surgical outcomes.
Do doctors wait too long to ask the patient how they are doing after surgery? Is this causing failed back surgery syndrome?
A March 2018 study (18) suggested their was too much variation in the follow up post-surgical period and this delay in follow up may be causing failed surgical outcomes. This may be why the numbers of failed back surgeries in the above study nearly doubled from six months post-op to one year post-op. In this paper, the researchers suggested that early postoperative results appeared to herald the longer term outcome. As such, a ‘wait and see policy’ in patients with a poor initial outcome at 3 months is not advocated.” Not reacting sooner to the apparent problems of the patient “could result in a failure to intervene early to achieve better long-term outcomes.”
Does having an MRI to help diagnose failed back surgery syndrome help? Should an MRI after surgery even be done?
A prepublication online December 2022 paper (19) writes: “Adequate treatment of failed back surgery syndrome is challenging, as its etiology is believed to be multifactorial and still not fully clarified. Accurate identification of the source of pain is difficult but pivotal to establish the most appropriate treatment strategy. Although the clinical utility of imaging in failed back surgery syndrome patients is still contentious, (debatable if having a post-surgical MRI is warranted, needed or even advised) objective parameters are highly warranted to map different phenotypes of failed back surgery syndrome and tailor each subsequent therapy. Although many imaging studies have been performed in failed back surgery syndrome patients, they are primarily focused on the preoperative setting or are not correlated with the patient’s symptoms in order to assess whether failed back surgery syndrome was indeed present and, if so, what imaging could have offered in failed back surgery syndrome patients specifically. Therefore, more evidence concerning imaging in failed back surgery syndrome patients is warranted, particularly for determining the source of pain and planning of follow-up treatment.”
“A number of controversial issues concerning the management of failed back surgery syndrome are regularly debated, but no clear consensus has been reached.”
In a July 2019 (20) paper, spinal surgeons and neurosurgeons tried to come up with a program to help people with Failed Back Surgery Syndrome. They wrote: “A number of controversial issues concerning the management of failed back surgery syndrome are regularly debated, but no clear consensus has been reached. (On how to treat it). . . “Failed back surgery syndrome results from a cascade of medical and surgical events that have led to and left the patient with chronic back and radicular pain. This pain often remains refractory to sporadic management strategies for a considerable proportion of these patients. . . “
An August 2022 paper (21) noted: “The most common reasons for early reoperation and late operation were surgical site infection and adjacent segment diseases, respectively. Osteoporosis and diabetes were independent risk factors for early reoperation, and multilevel fusion was independent risk factor for late reoperation. ”
ain and fear of movement following spinal surgery
Let’s look at two studies, seven years apart, from the same learning institute. The research concerns pain and fear of movement following spinal surgery and which patients would be at greater risk for poorer recovery.
From 2011: Patients with back pain have many concerns and fears when it comes to being able to move pain-free. Surgery is supposed to take care of this fear. Researchers from the University of Gothenburg, Sweden (22) followed 97 patients after their spinal disc surgery looking for a post-surgical occurrence of kinesiophobia “fear of movement,” a tell-tale sign of unsuccessful back surgery. What they found was surprising.
- Half of the patients suffered from kinesiophobia 10-34 months after surgery for disc herniation.
- Prior to surgery these patients were already classified as more disabled, had more pain, more catastrophizing thoughts, more symptoms of depression, lower self-efficacy, and poorer health-related quality of life than patients.”
For many whom surgery would seemingly be most helpful, the surgery itself did not reverse their problems and made their fear of extremely painful movement worse
Seven years later, 2018. A different team of researchers from the University of Gothenburg, Sweden (23) recruited a study in 2016 which they hoped would help patients following spinal surgery with problems of health-related quality of life, back and leg pain intensity, pain catastrophizing, kinesiophobia, depression, and anxiety. In 2018 they published their findings:
“A high proportion of the patients did not reach the WHO (World Health Organization) recommendations on physical activity and are therefore at risk of poor health due to insufficient physical activity. We also found a negative association between both fear of movement and disability, and the number of steps per day. Action needs to be taken to motivate patients to be more physically active before surgery, to improve health postoperatively. There is a need for interventions aimed at increasing physical activity levels and reducing barriers to physical activity in the prehabilitation phase of this patient group.”
In November 2019, (24) another study confirmed these findings:
“Depression and fear of movement were more important predictors of the execution of activities of daily living and participation in social life compared to morphological (internal structure damage) markers. Elevated depressive symptoms and fear of movement might indicate limited adaptation and coping regarding the disease and its consequences.”
A heightened sense of pain from an altered pain processing center
A November 2022 study (25) examined the problem of altered central pain processing in failed back surgery syndrome patients. Altered central pain processing sounds exactly as to what is is. You have an altered sense of pain (worse pain than you should) and it is coming from the central nervous system. In this study, the researchers found that the 34 patients diagnosed with failed back surgery syndrome were more sensitive to pressure sensation and a conditioned pain modulation. The doctors tested the patients with a pain stimulus. While the pain stimulus was not increased, over time the patient felt more pain from the same stimulus.
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References:
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