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Back, or spine surgery in general, carries with it a significant degree of patient risk. It is therefore unfortunate when someone goes through surgery and is not better or worse. This situation is often referred to as "the failed back surgery syndrome (FBSS)." In 1981 an international survey (Canada and the United States) on FBSS was published in the peer reviewed journal "Clinical Orthopedics." It was felt, by the authors, that the first step in avoiding FBSS was to study the reasons why surgery failed and to endeavor to provide this information to surgeons and other physicians in an attempt to promote productive change for the patient. This has been a slow process.
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This 1981 clinical study documented that the most common surgical reason for a poor post-operative spine surgery result was failure to either adequately diagnose and/or failure to adequately relieve, a condition referred to as "lateral spinal stenosis (LSS)." In the Department of Orthopaedic Surgery at the University Hospital in Saskatoon, in an analysis of 225 patients operated upon over a 10 year period, it was found that in 56% of patients diagnosed with a herniated disc concomitant lateral spinal stenosis or lateral spinal stenosis alone was found at the time of surgery. At the beginning of the 21st century LSS continues to be the most common reason for the Failed Back Surgery Syndrome. In addition, as of the year 2004 no other clinical study has ever been performed or published regarding the structural (anatomic) reasons for the existence of the "failed back surgery syndrome"! Why does this situation continue to exist, given the fact that there are about 500,00 spine surgeries performed in the United States each year? Frankly, it is beyond the comprehension of the Burton Report to comprehend this but the existence of hidden agendas and personal gain appear to be part of the problem. Another important reason has to do with inadequate training on the part of spine surgeons and continuing ignorance of important information. While many cases of lateral spinal stenosis are due to congenital spine disorders and progressive spine degeneration related to this, many other cases are iatrogenic, produced by rigid instrumented stabilization procedures causing "transitional changes" and creating more problems for a patient than they solve. With the universal advent of high-resolution magnetic resonance scanning accurate, non-invasive, information is now readily available to all physicians. Many physicians simply do not know what to do with this important information. Whether due to apathy, ignorance, or indifference this sad situation is unlikely to change until the public becomes better informed in such matters and starts asking more perceptive questions. |
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The simplest, and most effective means of decompressing a nerve root compromised by lateral spinal stenosis is to remove a portion of the adjacent inferior pedicle as shown in the illustration above from 1981. With this the operator can ascertain, with certainty, that adequate nerve compression has been achieved rather than gambling on the result for the patient.
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The most common reason for not definitively achieving a balgreat dealtable nerve appears to be the common desire, on the part of the operating surgeon to preserve the vertebral pedicle in order to accommodate pedicle screws. Spine surgeons not trained in the posterior placement of titanium cages are most likely to fall prey to the inadequate treatment of LSS and thus contribute to ever increasing numbers, and continuing expense, of FBSS patients. |
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Perhaps the saddest FBSS situation is when a patient is worse following surgery but the reason for this is not related to the surgery but to something else. From the 1930s to the 1980s many patients who underwent pre-operative oil myelography with neurotoxic agents such as lipiodol or iophendylate (Pantopaque®, Myodil®, etc.) developed clinically significant adhesive arachnoiditis as a result of this exposure and many remained permanently incapacitated by constant pain following surgery. The 1981 study indicated that over 11% of FBSS cases were due to adhesive arachnoiditis alone. In addition to this the scar tissue resulting from the inflammation caused by these agents often produced abnormal patterns (due to scarring alone) on subsequent myelograms which were incorrectly interpreted by radiologists as showing "recurrent disc herniation" thus leading to additional (unnecessary) spinal surgery being carried out. This sad, but continuing, neuropathologic process was an important part of the reason that back surgery has carried such an adverse stigma for so many past decades. |
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