The best tactic to allow for improving airline safety is to study the reasons why planes crash. The same is true in the field of spine surgery. The exorbitant cost of spine care is only matched by the very high cost of spine surgery, particularly of the ill-advised variety. The reasons as to why spine surgery fails have been studied and well-documented but, over two decades later, these known surgical transgressions continue unabated. The reasons for this are complex but basically reflect poor information transfer and poor quality control by the medical profession. In all fairness there are those who are doing their best to change this situation but progress is slow.
Sadly, many of the individuals who have spine surgery recommended do not receive adequate information regarding effective non-surgical alternatives and, on the basis of this, can not have true informed consent.
Yet, the reality is that there are legions of “failed back surgery cases” (FBSS) throughout the world. These individuals are disabled and often desperate. The management of such cases reflects the best, as well as the worst, of the medical community.
One prominent spine specialist from Glasgow, Scotland has pointed out, for many years, at International meetings, that in Scotland; if a patient does not do well after an operative procedurethey are never given a second surgery. This scenario smacks of disrespect as do the belief that if a patient does not do well after surgery then they must have psychiatric problems. One American surgeon was known to routinely offer to exorcise the demons from failed back surgery patients to assist in their recovery.
The best scenarios reflect knowledge and skill by which FBSS patients can be salvaged and provided with some quality of life. For certain problems such as adhesive arachnoiditis such salvage is limited but for those with undiagnosed or untreated problems such as lateral spinal stenosis the outlook is significantly better.
There are few things more rewarding to a spine surgeon than to effectively “salvage” a patient who has undergone one or more operative procedures and has continued to be disabled.
The drawing on the left illustrates subarticular (spinal recess) and lateral spinal stenosis. The drawing, published originally in 1981 by the Editor, has been published in peer reviewed journals, books, and has been the subject of numerous presentations at national and international meetings. In 1981 these entities were the most common reasons for back surgery to fail.
At the turn of the century they still remain the most common reason for failure of back surgery. It is the Editor’s belief that over 90% of FBSS cases result from physician lack of knowledge.
The remarkable disparity between the providing of medical information and the absorption of of this is not easy to clarify, but the phenomenon has been proven over time. It rests in the hands of the consumer, the patient, to become informed so that they can serve as external impactors upon their physicians to promote change.
The following cases represent examples of the continuing phenomenon of failed back surgery:
The series of images above depict the saga of a 78 year old executive (picture shown with permission) who was operated upon at a major spine center because of a lumbar-claudication-type pain in his left leg. After an operative procedure his pain was not improved but the surgery was complicated by a dural tear and cerebro-spinal fluid leak. The leak did not respond to two weeks of bed rest (complicated by thrombophlebitis and embolus) or a attempted dural repair. When seen for evaluation this patient continued to have his original problem as well as postural headache and a lumbar mass (containing spinal fluid). The salvage surgery involved adequate decompression of the still-present lateral spinal stenosis (red dot above) in association with a lateral disc herniation and repair of the continuing dural defect, pseudomeningocoele, and subcutaneous spinal fluid accumulation (pseudomeningocoele shown by yellow dots). Segmental instability was found at two levels and fusion with titanium cages was also done (blue dots). Patient was relieved of his problems and returned to normal function as well as his favorite pastime (playing golf).
Dural tears are a possible complication of any operative procedure but they are more common in salvage surgery. Adequate imaging information was provided to the original surgeons, it is clear that they did not know what to do with it, such a circumstance is not a justification for a poor operative result.
This 54 year old retired IBM network support specialist had undergone 8 previous operative procedures on the lumbar spine. He continued to be incapacitated by a right sciatic neuropathy due to underlying unresolved lateral spinal stenosis associated with and unstable spine. Salvage surgery involved the removal of the 7 level TSRH instrumentation (shown re-assembled by the patient) removal of extensive post-surgical scar tissue, partial take-down of fusion, repair of dural rears and re-fusion utilizing autologous bone. Patient is shown 6 months after surgery. (picture shown with patient permission).
This patient is a 67 year old certified public accountant who developed incapacitating pain in the right leg. Two decompressions were performed in his home state less than two months apart. Neither improved his pain or disability.
Upon evaluation it was evident that there was a significant lateral listhesis (red line) in addition to residual lateral spinal stenosis. At the time of salvage surgery it became evident that only hemi-laminectomies involving the central zone of the spinal canal had been performed previously. Neither operative procedure addressed the existing multi-level nerve compression. Following adequate surgical decompression of the compromised nerves multi-level pedicle screw and rod stabilization was performed. Immediately after salvage surgery this patient’s right leg pain was gone. All of this patient’s original MRI studies clearly demonstrated long-standing lateral spinal stenosis.
Once again, in the continuing Burton Experience, failure to diagnose or to adequately treat lateral spinal stenosis remains the most common cause of FBSS. The Editor has seen a series of patients with this problem receiving only central spinal canal decompressions at a major medical clinic. All such patients have required additional salvage surgery. Because of the iotrogenically created scar tissue these cases are much more difficult to salvage from the technical standpoint. All that their initial surgery accomplished was to make the patients worse and increase the risk factors for salvage surgery. Yet, when such patients return to their original surgeons for advice they have been told:
“Don’t let anyone else operate on you because you will be paralyzed for sure.”
“The risk of any additional surgery is so high that you are not a candidate for this.”