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Failed Spine Surgery

Introduction

  • one of the greatest problems in orthopaedic surgery and neurosurgery
  • persistent or recurrent pain in the back or lower limbs is relatively common after an operation on the lumbar spine
  • long-term rates of failure after primary operations have been reported to be as high as 30 per cent after lumbar arthrodesis and 37% after lumbar discectomy
  • enormous cost to society in terms of medical expenditures and lost productivity
  • Frymoyer - re-operation rate: 11% after arthrodesis and 13% after simple discectomy had needed at least one additional operation on the spine by the time of the ten-year follow-up evaluation
  • medical literature is inconsistent with regard to the results of re-operations after failure of previous operations on the spine - good result 12 - 82 per cent
  • Waddell et al. - probability of a successful outcome of a revision operation on the lumbar spine decreases with each subsequent procedure
  • a more extensive previous procedure, as evidenced by the number of operative levels, was associated with a poor outcome
    • difficulty in localizing the anatomical source of pain

Epidemiology and Economics

  • In industrialized societies, the prevalence of back pain over the course of a lifetime in the entire population is more than 70%
  • incidence of back pain in the United States is 15-20% per year
  • most frequent cause of limitation of activity among individuals < 45 yrs.
  • second most common symptom necessitating a visit to a physician
  • 1% of the population in the United States is chronically disabled because of low-back pain and an additional 1 percent is temporarily disabled
  • rate of lumbar arthrodesis increased by 200% between 1979 and 1987
  • rate of operations on the lower back increased an additional 100 percent
  • estimated that in the United States the direct and indirect cost of all conditions related to the spine ranges from thirty-eight to fifty billion dollars per year

Natural history of lumbar disc disease / Low back pain

  • natural history of the disc sy. is towards resolution
    • Holmes & Rothman - 90% resolve spontaneously within 3 months
    • Singer - similar findings
    • Weber (Spine 1983) - results of disc dx treated operatively at 1 year was far better than those treated non-operatively BUT, at 4 & 10 year follow-up, the results were the same
  • neurological results improved just as well in the conservatively treated group as the operative group
  • natural course of herniated discs - decrease in size (serial CT scans) - Thelander & others

Theory of spinal degeneration

  • all spines degenerate
  • present methods of treatment are for symptomatic relief, not for a cure
  • degenerative process divided into three separate stages

1st stage - dysfunction

  • age group - 15-45 years
  • tears in the disc anulus & localized synovitis of the facet joints
  • familial predisposition to lumbar disc herniation in patients who had herniation before age 21 years

2nd stage - instability

  • 35-70-year-old patients
  • internal disruption of the disc progressive disc resorption, degeneration of the facet joints with capsular laxity, subluxation & joint erosion

Final stage - stabilization

  • patients older than 60 years
  • development of hypertrophic bone about the disc and facet joints
  • leads to segmental stiffening or frank ankylosis
  • each spinal segment degenerates at a different rate
    • one level is in dysfunction, another may be entering stabilization stage
  • disc herniation a complication of disc degeneration in dysfunction & instability stages
  • spinal stenosis from degenerative arthritis is a complication of bony overgrowth compromising neural tissue in the late instability & early stabilization stages
  • males were found to have more degeneration than females
  • L4-5 & L3-4 disc levels showed the greatest degree of disc degeneration

Results of surgery

  • failure rate of surgery for pain relief d/t disc herniation is high (reported by several authors)
  • significant morbidity also present post-op.

Why surgery often fails

    • main cause of surgical failure = poor patient selection
    • inaccurate diagnosis
    • back pain & sciatica can originate from a number of sites
  • X rays, CT scans & MRI’s are only of relevance if the findings are supported by clinical findings
  • to operate on the basis of special investigations only is unacceptable
  • must also remember:
    • diabetes can mimic a herniated disc
    • ischaemia of the cauda equina & nerve roots are a cause of intermittent claudication
    • psychogenic factors

Causes of failed back

  • numerous reasons for the failures

Poor patient selection

  • secondary gain, WCA claims, litigation
  • psychosocial problems - were prevalent, but were not initially recognized
    • drug abuse
    • alcoholism
    • marital discord
    • personality disturbances
  • smoking
    • negative linear association with outcome
    • cessation of smoking before the operation positively affected the outcome

Recurrent herniation

  • usually acute recurrence of signs & symptoms following 6-12-month pain-free interval)

Gerniation at another level
Discitis

  • occurs 3-6 weeks postoperatively with rapid onset of severe back pain)

Unrecognized lateral stenosis

  • may be most common

vertebral instability

  • unrecognized or iatrogenic/postoperative
  • rates reported in the literature have ranged widely (from 8 - 66%)
  • controversy - may or may not cause continuing symptoms after failed arthrodesis

Failure of instrumentation

  • usually with pseudoarthrosis
  • may be poor surgical technique

Epidural fibrosis

  • occurs at about 3 months postoperatively
  • may be associated leg pain
  • related to hemorrhage and surgical trauma and responds poorly to re-exploration
  • scar can best be differentiated from recurrent HNP with a gadolinium-enhanced MRI

Factors influencing outcome

  • best results from repeat surgery for disc problems appear to be related to the discovery of a new problem or identification of a previously undiagnosed or untreated problem
  • Waddell et al. - best results from repeat surgery
    • if patient had 6 months or more of complete pain relief after 1st procedure
    • leg pain exceeded back pain
    • definitive recurrent disc could be identified
    • young patients
    • female patients
    • absence of epidural scar requiring surgical lysis
    • employment before surgery
  • adverse factors
    • scarring
    • previous infection
    • repair of pseudarthrosis
    • adverse psychologic factors
    • secondary gain
    • smoking
  • similar factors were identified by Lehmann and LaRocca and Finnegan et al.
  • satisfactory results from reoperation reported to be from 31% to 80%
  • patients should expect improvement in the severity of symptoms rather than complete relief of pain
  • as the frequency of number of repeat back surgeries increases, the chance of a satisfactory result drops
  • Spengler et al. and Long et al. - major cause of failure is improper patient selection

Treatment plan

  • recurrence of symptoms after spine surgery should be treated with the usual conservative methods initially
  • if these methods fail to relieve the pain, a complete re-evaluation should be performed
  • frequently a repeat history and physical examination will give some indication of the problem
  • additional testing
    • psychologic testing
    • myelography
    • MRI to check for tumors or a higher disc herniation
    • reformatted CT scans to check for areas of foraminal stenosis or for lateral herniation
  • use of the differential spinal, root blocks, facet blocks, and discograms also may help identify the source of pain
  • a distinct, surgically correctable, anatomic problem should be identified before surgery is contemplated

Lumbar Arthrodesis for the Treatment of Back Pain
Current Concepts Review

  • lumbar arthrodesis is a commonly performed operative procedure for the treatment of low-back pain
  • indications, techniques, and results remain controversial and unclear
  • concept of spinal arthrodesis is based on experience with other regions of the body in which arthrodesis has been used to treat painful joints by eliminating motion
  • initial indications
    • infectious conditions
    • deformity
    • trauma of the spine
  • indications have been expanded
    • instability - control pain attributed to abnormal or unstable motion segment
    • pain due to mechanical degeneration of the intervertebral disc (discogenic pain)
  • spinal arthrodesis should be performed only after a specific pathoanatomical diagnosis has been identified as being responsible for the patient’s symptoms
  • natural history of the diagnosis and the appropriate timing of operative intervention should be understood

Epidemiology and Economics

  • In industrialized societies, the prevalence of back pain over the course of a lifetime in the entire population is more than 70%
  • incidence of back pain in the United States is 15-20% per year.
  • most frequent cause of limitation of activity among individuals < 45 yrs.
  • second most common symptom necessitating a visit to a physician
  • 1% of the population in the United States is chronically disabled because of low-back pain and an additional 1 percent is temporarily disabled
  • rate of lumbar arthrodesis increased by 200 percent between 1979 and 1987
  • rate of operations on the lower back increased an additional 100 percent
  • estimated that in the United States the direct and indirect cost of all conditions related to the spine ranges from thirty-eight to fifty billion dollars per year

Etiology of Axial (Nonradicular) Low-Back Pain

Facet Joints

  • degeneration of facet joints as a cause of low-back pain was first postulated in 1933
  • the theory remains controversial
  • nociceptive nerve fibers have been identified in facet-joint capsules and in synovial and pericapsular tissue
  • disappointing results have been reported with use of facet-joint injections

Intervertebral Discs

  • believed that a degenerated disc is the most likely source of chronic, disabling low-back pain (discogenic pain, internal disc disruption)
  • excision of the disc and interbody arthrodesis, have been used extensively
  • studies also have demonstrated that degeneration of the disc may not be painful
    • Boden et al. - MRI in asymptomatic patients - abnormalities 33%
  • innervation of the intervertebral disc - meningeal (sinuvertebral) nerve branches
  • severely degenerated lumbar discs have a more extensive innervation than do normal discs

Degenerative Instability

  • controversial indication for spinal arthrodesis
  • degeneration of the lumbar spine occurs in three phases:
    • dysfunction (progressive tearing of the annulus fibrosus, degeneration of the nucleus pulposus, and arthropathy of the facet joints)
    • instability (laxity of the facet joints, ligaments, and discs)
    • restabilization (formation of osteophytes and hypertrophy of the facet joints)
  • natural history of instability - restabilization in 20% at minimum ten-year follow-up
  • abnormal translational motion –> 4mm of anterior displacement defined instability

Psychological Factors

  • issues of secondary gain related to low-back pain include
    • financial gain from disability insurance or Workers’ Compensation
    • sick-role-related psychological gain
  • reaction to pain is a taught behavior based on socialization
    • Australian aborigines -Nearly half of the fifty-six adults had long-term back pain
    • because of their cultural beliefs, they chose not to make their pain public
  • identifiable psychological stress also correlates with LBP

Diagnostic Studies

  • plain radiographs
    • symptoms have persisted for more than four to eight weeks
    • associated with pain at night or at rest
    • rule out infection, a malignant lesion, fracture, and inflammatory conditions
    • negative results may help to reassure the patient - no major pathological condition
  • provocative discography
    • controversial
    • some base decision for fusion on ~
    • reproduction of the symptoms - select the levels to be included in the arthrodesis
  • magnetic resonance imaging (MRI)
    • non invasive method for evaluation of the disc
    • black disc disease - not necessarily symptomatic

Nonoperative Treatment

  • drug therapy
    • nonsteroidal anti-inflammatory drugs
    • muscle relaxants
    • narcotics, sedatives should be avoided
  • bed rest
    • brief period (two days) is advisable
    • additional bed rest may lead to deconditioning and development of illness-related behavior
  • active exercise, staying active
    • combination of flexion and extension
    • aerobic conditioning, and stretching
    • back school
    • best regimen is not known
  • manipulation
  • corsets, bracing
  • controversial or not proven
    • acupuncture
    • transcutaneous electrical nerve stimulation (TENS)
    • traction
    • facet joint injections
  • epidural steroid injection
    • for resistant cases

Operative Treatment

  • controversy exists regarding specific operative treatment for low-back pain
  • considered when nonoperative measures have been exhausted and disability and pain are still present
  • use of arthrodesis for the treatment of low-back pain may be associated with morbidity
    • twice as many complications for those who had had an arthrodesis as for those who had not

Posterolateral Arthrodesis

    • most commonly performed
    • with autogenous bone graft
    • with or without internal fixation
    • fusion mass is sufficiently close to the center of vertebral motion to prevent movement that may stimulate a pain response

Instrumentation

    • theoretical purpose of adding instrumentation - to increase the rate of fusion
    • various systems for posterior stabilization - wire, hook, and pedicle-screw-based constructs
    • may increase complications - nerve-root, spinal cord, and vascular

Anterior Lumbar Interbody Arthrodesis

    • developed for the treatment of tuberculosis
    • Cloward popularized for the treatment of axial low-back pain
    • excision of the disc - thought to remove the source of pain and to prevent motion
    • excellent vascularity - high fusion rate
    • injury to the great vessels and the presacral plexus

Posterior Lumbar Interbody Arthrodesis

    • only feasible in the lower back - no cord in the way
    • difficult
    • may use alone or as adjunctive to PLF

Interbody Fusion Cages

    • provide immediate structural support
    • filled with autogenous bone to promote fusion
    • anterior or posterior

Circumferential Arthrodesis (360° fusion)

    • first used for the treatment of trauma and deformity
    • posterior approach alone or a combined anterior and posterior approach

Intervertebral Disc Prosthesis

    • controversial and investigational
    • two basic groups - replace all of the disc or replace the nucleus pulposus only

Conclusions

  • available information on the diagnosis and treatment of low-back pain lacks objectivity
  • most studies have been retrospective, uncontrolled, and predominantly focused on operative technique
  • so-called facet disease and degenerative instability are extremely rare, and these diagnoses should seldom be used as indications for operative intervention
  • most patients who have acute or chronic idiopathic or discogenic low-back pain should be managed nonoperatively
  • patients who have refractory pain with severe incapacity, and those who have imaging-confirmed morphological changes and concordant symptoms, may be managed arthrodesis
    • some improvement occurs as a result of operative treatment in about 75% of patients
    • major or complete relief of pain and recovery of function are seen in 50 percent or less
    • each physician and each patient must assess these issues in a forthright manner and determine what is appropriate under the circumstances

Repair of a Pseudarthrosis of the Lumbar Spine.
A Functional Outcome Study

Summary

  • 86 patients had repair of a pseudarthrosis
  • solid fusion was ultimately achieved after the treatment of eighty-one (94%)
    • no significant association between a solid fusion and the patient’s age, gender, body-mass index, return to work, or outcome score
  • despite the high rate of fusion only 26% had a good or excellent outcome
  • 54 per cent had a poor result
  • smoking
    • negative linear association with outcome
    • cessation of smoking before the operation positively affected the outcome
    • patients who had stopped smoking were also more likely to return to work full time
  • Workers’ Compensation receiving patients
    • did poorly on the outcome questionnaire

Spinal fusion & Pseudoarthrosis

  • localized fusion of the lumbar spine done for various reasons
    • infection
    • fracture
    • scoliosis
    • intervertebral disc disease
    • and mechanical instability
  • one of the most common complications is pseudarthrosis
    • rates reported in the literature have ranged widely (from 8 - 66%)
  • controversy - pseudarthrosis may or may not cause continuing symptoms after failed arthrodesis
    • operative repair therefore is not always mandatory
    • others say patients may be helped by repair
  • operative repair of a pseudarthrosis - salvage procedure
    • reported results not always been encouraging
    • rate of successful repair has ranged from 49 - 94%
    • depend on many factors, such as smoking, metabolic disease, previous operations on the back, and the use of instrumentation

Failed back surgery syndrome: 5-year follow-up in 102 patients undergoing repeated operation.

  • indications for repeated operation in patients with persistent or recurrent pain after lumbosacral spine surgery are not well established
  • 102 patients with “failed back surgery syndrome” (averaging 2.4 previous operations), who underwent a repeated operation for lumbosacral decompression and/or stabilization
  • successful outcome 34% of patients
  • 21patients who were disabled preoperatively returned to work postoperatively, 15 who were working preoperatively became disabled or retired postoperatively
  • Improvements in activities of daily living were recorded, overall, as often as decrements
  • Loss of neurological function (strength, sensation, bowel and bladder control) was reported by patients more often than improvement
  • Most patients reduced or eliminated analgesic intake
  • Favorable outcome also was associated
    • young patients
    • female patients
    • history of good results from previous operations
    • absence of epidural scar requiring surgical lysis
    • employment before surgery
    • predominance of radicular (as opposed to axial) pain

The failed posterior lumbar interbody fusion

  • cases of 12 patients who presented with failed PLIF were reviewed
  • all patients underwent at least one PLIF; many had undergone other procedures
    • total of 37 procedures had been performed on the 12 patients
  • chronic radiculopathy was present in all patients
  • at the time of reconstructive surgery, in the 11 patients in whom the canal was explored, all had extensive epidural fibrosis
  • Nine of the 12 patients had pseudarthrosis of the previous PLIF
  • Four patients had evidence of motion segment dysfunction at nearby levels: two had positive discograms adjacent to the PLIFs; one developed a facet syndrome at L5-S1, caudal to an L4-5 PLIF; and one demonstrated frank segmental instability at L2-3, cranial to a previous PLIF at L3-4
  • Twelve patients underwent a total of 22 procedures after referral
    • 11 decompression and fusion
    • one patient underwent a sympathectomy
    • 7 patients underwent an additional 10 procedures, including repeat decompression, repair of pseudarthrosis, and implantation of an epidural analgesic pump system
  • after all surgical treatment 5 patients rated their pain as improved
  • 7 patients were thought to have a solid fusion
  • presence of a solid fusion did not correlate with satisfactory relief of pain
  • Continued extremity pain was the predominant complaint of all the patients.

Clinical correlates of patient satisfaction after laminectomy for degenerative lumbar spinal stenosis

  • multicenter observational study of the outcome of surgery for degenerative lumbar spinal stenosis
  • OBJECTIVES. To identify correlates of patient satisfaction with the results of surgery.
  • METHODS. Preoperative and 6-month follow-up data for 194 patients were analyzed. Associations between preoperative variables and satisfaction with the results of surgery were examined
  • RESULTS - the predominance of back (as opposed to leg) pain, greater co-morbidity, and worse preoperative functional status were associated with lower patient satisfaction

Seven - to 10-year outcome of decompressive surgery for degenerative lumbar spinal stenosis

  • Retrospective review and prospective follow-up of 88 patients who had decompressive laminectomy with or without fusion from 1983 to 1986.
  • OBJECTIVE: To determine the 7 - to 10-year outcome of surgery
  • METHODS: Patients completed standardized questionnaires in 1993 that included items about reoperations, back pain, leg pain, walking capacity, and satisfaction with surgery
  • RESULTS: Average preoperative age was 69 years and eight patients received fusion. Of 88 patients in the original cohort, 20 (23%) were deceased and 20 (23%) had undergone reoperation by 7 - to 10-year follow-up. Thirty-three percent of the respondents had severe back pain at follow-up, 53% were unable to walk two blocks, and 75% were satisfied with the results of surgery.
  • CONCLUSIONS: 7 to 10 years after decompressive surgery for spinal stenosis, 23% of patients had undergone reoperation and 33% of respondents had severe back pain. Despite a high prevalence of nonspinal problems in this elderly cohort, spinal symptoms were the most important correlate of reduced functional status.

Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes.

  • OBJECTIVES:
      1. Identify correlates of the decision to perform arthrodesis in patients undergoing laminectomy for lumbar spinal stenosis
      2. Compare symptoms, walking capacity, and satisfaction 6 and 24 months after laminectomy alone and laminectomy with noninstrumented and with instrumented arthrodesis.
  • METHODS: 272 patients undergoing surgery for degenerative lumbar stenosis by eight surgeons at four centers were included in the study cohort. Of these, 37 had noninstrumented and 41 had instrumented arthrodesis.
    • principal outcomes-health status, walking capacity, back and leg pain, and satisfaction with surgery-were assessed 6 and 24 months postoperatively
    • hospital costs were obtained
  • RESULTS
    • major predictor of the decision to perform arthrodesis was the individual surgeon
    • noninstrumented arthrodesis was associated with superior relief of low back pain at 6 months and 24 months
    • no significant differences in the other outcomes across treatment groups
    • hospital costs of laminectomy alone and noninstrumented and instrumented arthrodesis were $12,615, $18,495, and $25,914, respectively

Conservative treatment of acute and chronic nonspecific low back pain

  • OBJECTIVES: To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain
  • SUMMARY OF BACKGROUND DATA: Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy.
  • METHODS: A rating system was used to assess the strength of the evidence, based on randomized controlled trials, the relevance of the outcome measures, and the consistency of the results.
  • RESULTS: The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Strong evidence was found for the effectiveness
    • of muscle relaxants
    • nonsteroidal anti-inflammatory drugs
    • manipulation
    • back schools
    • exercise therapy for chronic low back pain, especially for short-term effects
  • CONCLUSIONS: The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.

Failed Anterior Cervical Discectomy and Arthrodesis. Analysis and Treatment of Thirty-five Patients

  • 35 patients were managed operatively after failure of an anterior cervical discectomy and arthrodesis
  • Failure was classified as the
    • absence of fusion without deformity but with neck pain or radiculopathy, or both
    • absence of fusion after anterior or posterior dislodgment of the graft
    • kyphosis due to collapse of the graft or to an unrecognized posterior soft-tissue injury
  • Twenty-three patients had failure of the arthrodesis without deformity (with neck pain only, neck and arm pain, radiculopathy, or myelopathy). Four patients had dislodgment of the graft; in two of them the graft migrated anteriorly after a multilevel Robinson arthrodesis, and in two it migrated posteriorly after a Cloward arthrodesis. Eight patients had a failure because of a kyphotic deformity. Five of them had had a Cloward arthrodesis; one, a discectomy; and two, a Robinson arthrodesis. Six had received allograft bone.
  • Operative treatment of the pseudarthrosis consisted of
    • repeat resection of the disc space in the area of the failed arthrodesis
    • followed by repeat anterior Robinson arthrodesis with decompression of the nerve root if the patient had radiculopathy
    • it consisted of anterior corpectomy or vertebral-body resection and strut-grafting with reduction of the deformity if the patient had migration of the graft and kyphosis
    • reoperations were performed four months to fourteen years (average, thirty-two months) after the initial operation
    • duration of follow-up after the second operation averaged forty-four months (range, twenty-four to 216 months)
  • result was excellent for twenty-nine patients, good for one, fair for four, and poor for one.

Current Concepts Review - Interbody Fusion Cages in Reconstructive Operations on the Spine

  • During the last five years, surgeons around the world have inserted more than 80,000 lumbar interbody fusion cages; in the United States alone, an estimated 5000 such devices are implanted each month.
  • recent interest in performing lumbar interbody arthrodesis with use of cages is attributable to three factors
    • the high rate of failure associated with use of bone graft alone
    • the high rate of failure associated with use of posterior pedicle-screw instrumentation
    • high rate of success associated with use of so-called stand-alone anterior fusion cages and autogenous bone graft, obviating the need to perform a 360-degree (combined anterior and posterior) lumbar arthrodesis with use of posterior instrumentation

Patient Outcomes after Reoperation on the Lumbar Spine

  • thirty-nine patients who had had a reoperation on the lumbar spine was followed for an average of forty-eight months
  • patients were evaluated with regard to pain, functional status, and work status
  • 72% had a successful outcome, as determined by their ability to return to work, their lack of a need for narcotic analgesics, and their satisfaction with the operative result
  • Factors that associated with a successful outcome
    • younger age
    • working outside of the home
    • an initial period of improvement after the previous (index) operation
    • fewer spinal levels operated on previously
    • revision procedure incorporating anterior interbody fusion
  • persistent or recurrent pain in the back or lower limbs is relatively common after an operation on the lumbar spine
  • long-term rates of failure after primary operations have been reported to be as high as 30 per cent after lumbar arthrodesis and 37% after lumbar discectomy
  • enormous cost to society in terms of medical expenditures and lost productivity
  • Frymoyer - re-operation rate: 11% after arthrodesis and 13% after simple discectomy had needed at least one additional operation on the spine by the time of the ten-year follow-up evaluation
  • medical literature is inconsistent with regard to the results of reoperations after failure of previous operations on the spine - good result 12 - 82 per cent
  • Waddell et al. - probability of a successful outcome of a revision operation on the lumbar spine decreases with each subsequent procedure
  • a more extensive previous procedure, as evidenced by the number of operative levels, was associated with a poor outcome
    • difficulty in localizing the anatomical source of pain

Repeat lumbar spine surgery.
Factors influencing outcome

  • 45 patients who had residual symptoms after lumbar spine surgery were re-evaluated and underwent additional surgery
  • After a minimum of 2 years’ follow-up, these patients’ results were reviewed to determine what variables might predict long-term outcome
  • Non significant
    • age
    • number of previous operations
    • psychological diagnosis
  • significant factors for good outcome
    • non-compensable injury
    • ability to return to work after surgery
    • negative history of litigation

Redecompression and fusion in failed back syndrome patients

  • between 1979-1985, 45 patients underwent redecompression, neural exploration, and lateral mass fusion for failed back syndrome
  • average follow-up was 29.2 months
  • 47% had good results, 22% fair and 31% poor
  • factors correlate with a poor result
    • Workers’ Compensation cases
    • less than six months pain free interval from the previous operation
    • male sex
    • history of psychiatric illness
    • diagnosis of perineural fibrosis
  • factors for good outcome
    • meticulous surgical technique
    • careful selection of patients

Failed lumbar disc surgery requiring second operation. A long-term follow-up study

  • 45 patients who had lumbar disc surgery 10 or more years previously, and had required a second operative procedure, have been evaluated
  • failures occurred up to 16 years after the first operation
    • pseudoarthrosis in the patients who underwent spinal fusion
    • recurrent disc lesions at the same level as previous surgery in the patients who did not have fusion
  • clinical and functional results in the second group of patients who required a second procedure were comparable to those of patients who required only a single procedure
  • patients who had undergone spinal fusion who required a second procedure had significantly worse clinical and functional results
  • repair of pseudoarthrosis did not lead to symptomatic relief
  • spinal fusion, when it fails, has a significantly worse prognosis than simple disc excision in the management of lumbar disc disease

Revision surgery for failed back surgery syndrome

  • results of surgical treatment in 50 failed back surgery patients were retrospectively reviewed
  • before surgery, all patients had disabling pain and limited function
  • significant improvement in pain and function was obtained in 66%
    • 81% who had successful fusion of pseudarthrosis had a satisfactory outcome
    • 23% who had failed pseudarthrosis repair had a satisfactory outcome
  • success rate of reoperation on failed back surgery syndrome patients is low.

Low-back pain following multiple lumbar spine procedures. Failure of initial selection?

  • retrospective review of 30 patients who had failed multiple traditional surgical procedures for low-back pain, sciatic pain, or both
  • most common cause of the poor results - failure of initial selection
    • even though all patients appeared to meet traditional indications for operative intervention
  • psychosocial problems - were prevalent, but were not initially recognized
    • drug abuse
    • alcoholism
    • marital discord
    • personality disturbances

Failed lumbar disc surgery and repeat surgery following industrial injuries.

  • 179 of the compensation patients who had one low-back operation had to have repeat back surgery
  • Many had residual back pain, limited lumbar movement, presisting nerve-root deficits, and psychological disturbances
  • 40% of the second operations were successful
  • subsequent operations yielded progressively poorer results and made more patients worse than better
  • operations were frequently undertaken without clear indications or evidence of correctable organic lesions
  • results of repeat operations were better
    • preceding operation had given more than six months’ relief
    • sciatica overshadowed back pain
    • definite recurrent disc herniation was found
  • worse results if
    • scarring and neurolysis
    • previous infection
    • repair of a pseudarthrosis
    • adverse psychological factors
  • Careful patient selection based on total evaluation of the disability including psychological assessment, accurate localization of the lesion by detailed investigation, and, most important, a logical sequence of decisions based on clear, objective criteria are prerequisites for this complex and demanding surgery