The "Failed Back Surgery Syndrome": a Serious Public Health Concern
by The Burton Report
The July, 2004 of "The BackLetter" published by Lippincott contains the following inditement:
"The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate" (Vol. 12, No. 7, pp.79).
The validity of this declaration continues to be reinforced by an increasing chorus of voices from the health care communities including neurosurgeons and orthopedists. The key questions today are how this sad state of affairs came to be and how to best address this serious health care issue.
All spine surgery carries with it a significant degree of patient risk but when the resulting surgery does not alleviate the problem, or creates even greater problems for the patient, the situation is referred to as a "failed back surgery syndrome (FBSS)." In 1981 the Editor was a contributor to an international FBSS (Canada and the United States) study which was published in the peer reviewed journal "Clinical Orthopedics." The authors pointed out that the first step in avoiding FBSS was the need to study the reasons why surgery failed and to endeavor to provide this information to surgeons and other physicians as an important means of promoting better patient care.
This 1981 clinical study pointed out that the most common surgical reason for a poor post-operative spine surgery result was failure to either adequately diagnose or treat a condition referred to as "lateral spinal stenosis (LSS)." In the Department of Orthopaedic Surgery at the University Hospital in Saskatoon, an analysis of 225 patients operated upon over a 10 year period, demonstrated that 56% of patients diagnosed with a herniated disc also had concomitant lateral spinal stenosis (or lateral spinal stenosis alone) at the time of surgery.
Remarkably, at the beginning of the 21st century failure to diagnose of adequately treat LSS continues to be the most common reason for the Failed Back Surgery Syndrome. In addition, as of 2004 no other clinical study has been published regarding the structural (anatomic) reasons for the existence of this entity.
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 this online journal, but the existence of hidden agendas and personal gain appear to be important reasons behind this problem. Another important factor has to do with inadequate training on the part of spine surgeons and continuing physician ignorance in regard to understanding degenerative disease of the spine. Many cases of FBSS reflect failure to understand congenital spine disorders which have led to progressive spine degeneration and associated disability. Many other cases are iatrogenic in nature, produced by rigid instrumented stabilization procedures causing "transitional syndromes" and creating more problems for the patient than those being solved. As indicated below awareness regarding the alarming increase in spine surgery failures is in increasing evidence in the media. One example of this is the report (below) from the New York Times:
Professor Klaus-Peter Schulitz, Orthopaedic Department, Heinrich-Heine-University, Düsseldorf, Germany in an editorial published in the MedFak Orthopaedic Journal, March 22, 2004 made this important observation:
Neurosurgeon James Ausman, Editor of the journal Surgical Neurology, provided a neurosurgical viewpoint in his editorial published in the April, 2110 issue:
The Failed Back Surgery Syndrome situation today is a challenging one for patients with multi-level degenerative spine disease. Unless patients exercise due diligence in finding well-informed surgeons practicing according to the Hippocratic principles they are essentially gambling on their future.
Good information regarding surgeon , hospital, and procedure selection is contained within this website for those interested and willing to view it. Often the patient's best option is a non-invasive or minimally invasive one, as opposed to spine surgery.
The Basic Elements of Effective Spine Surgery
To be effective Spine Surgery must address some basic rules:
1. Adequate decompression of compromised nerve elements. 2. Spine stabilization must utilize the least invasive and most effective surgical techniques available. 3. The surgery must avoiding the creation of additional patient problems in the future.
The simplest, and most effective means of decompressing a nerve root compromised by lateral spinal stenosis (the most common reason for surgical failure) is to remove a portion of the adjacent inferior pedicle as shown in the illustration. With this the operator can ascertain, with certainty, that adequate nerve compression has been achieved rather than gambling on the result.
Spine surgeons not well trained in the posterior application of titanium cages, particularly the "POLAR" (posterior lumbar oblique arthrodesis) single cage technique are the ones most likely to fall prey to the inadequate treatment of LSS and thus contribute to ever increasing numbers, and continuing expense, of FBSS patients.
Failure Not Due To Surgery
Perhaps the saddest FBSS situation is when a patient is worse after adequate surgery but the reason for failure is not related to the surgery itself. 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. Furthermore, the scar tissue resulting from these agents often produced abnormal patterns on subsequent myelograms which were then incorrectly interpreted by radiologists as showing "recurrent disc herniations" thus leading to additional (unnecessary) spinal surgery. This sad, but continuing, disease entity has been another reason for FBSS and an important contributor to the reason why back surgery has carried with it such an adverse stigma for so many years.
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