What is Failed Back Surgery?
Self-evidently, failed back surgery is the outcome of surgical intervention that has been less than satisfactory in restoring a reasonable quality of life. This may be referred to as a ‘multiply-operated back’. In reality, these terms may be used as a mask to disguise the fact that the condition is normally deemed inoperable, that ‘nothing else can be done’, and that the final resort is to refer the patient for chronic pain management. There are some exceptions to this, but in terms of conventional surgery the available options are somewhat limited and include the following:
- Where a residual or recurrent bone protrusion is deemed contributory and is safely accessible by conventional means. This can be treated by revision discectomy (Microdiscectomy), with or without fusion at the same time.
- Where a successful discectomy has been performed but over ensuing years additional degeneration in the disc(s) and facet joint(s) is deemed to be causing the patient “discogenic” pain or “instability” then this may be treated by open decompression and/or fusion.
Where these factors do not apply or where fusion and/or total disc replacement has failed, then conventional treatment pathways will consign the patient to chronic pain management and cognitive behavioural therapy. Scarring around the nerve (Perineural Scarring) as a result of surgery, trauma or infection is difficult for conventional surgeons to treat, because the scarring is likely to recur. Minimally Invasive Spine Surgery using a laser or other high energy device can address these problems because tissue disturbance is targeted and minimised and tissue bleeding is sealed by the high energy sources such as the laser.
What is wrong with conventional diagnosis?
Conventional diagnosis is normally achieved by means of clinical findings and scans and X-rays. Unfortunately, X-rays may show impeccable surgery and scans all too often fail to show a pathology that is conventionally deemed to be significant enough to merit re-exploration.
What are the conventional treatments?
Conventional treatment for failed back or neck surgery usually the form of Chronic Pain Management with repeated steroid injections into facet joints, trigger points, the spinal space and around exiting nerve roots. These provide short-term benefits and gradually diminishing returns Additional injections may be used to induce scarring in and around ligaments to ‘stabilise’ the spine. These injections are usually combined with extensive medication in the form of opiates and anti-epileptic drugs. These have a detrimental impact on faculties, ability to work and lifestyle and are especially difficult for over-65s. In recalcitrant cases, a Dorsal Column Stimulator may be inserted to “blank off” the pain stimuli below the brain.
Why is aware state diagnosis better?
Conventionally the cause of the pain is diagnosed from the pattern of the pain and MRI scans but these techniques are inaccurate. However, the causal pain sources can now be accurately defined through aware state surgical examination, during which the surgeon seeks to replicate the pain by spinal probing. When this provokes a response, the patient, who is protected by circulating intravenous pain killers, offers feedback to the surgeon regarding the type and distribution of the pain produced. Sometimes, when the response is only partially akin to the presenting symptoms or when the response is at more than one spinal level, additional techniques are used to determine the relative importance of each site in the totality of the patient’s pain and condition. This defines whether the operated disc or an additional disc level is the cause of the pain. This is especially important in cases of Failed Back Surgery where the surgeon considers that the source of the presenting symptoms has already been adequately addressed.
Can the diagnosis be confirmed?
This can be achieved by the use of spinal probing of the nerve, contents of the foramen and epidural space to determine contributory levels. Hydraulic discography can be used to determine levels causing compression of the nerve exiting the spinal space. This procedure enables the surgeon to re-tension the disc and ligaments, restore disc height, realign the facet joints and restore the volume of the foramen at the suspected level. These techniques, which include the injection of an X-ray visible liquid into the disc, open up the ‘Foramen’ or spinal spaces and effectively liberate the nerve temporarily. Where pain rather than compression is the predominant symptom then insertion of anaesthetic or steroid in to the disc (Differential Discography) can be used to distinguish the role played by each level in the symptom complex. If these studies transiently reverse the symptoms, then the specific causal segment can be identified without having to open the back at several levels. This will demonstrate whether or not the original surgery addressed the causal segment in the first instance or whether it addressed the correct level but failed to correct the effects of the pathology at the operated level.
Is there a better alternative treatment?
Having determined the causal level, Transforaminal Endoscopic Lumbar Decompression & Foraminoplasty (ELDF) enables the surgeon to ‘walk up’ the exiting nerve root, make space in the foramen and the spine, ‘liberate’ the nerve and remove the factors causing the pain. The great benefit of ELDF is that it enables the surgeon to treat the condition specifically, precisely and with minimum collateral damage to tissues, reduced risk to the patient and enhanced long-term outcome.
Are there additional benefits?
After liberating the exiting nerve, the water jacket and nerves within the spinal canal as necessary, Laser, RF or other high energy sources can be used to remove scarring sufficiently to allow the nerve to recover its natural mobility and avoid further irritation. This also seals the operative bed and reduces clotting around the nerve so that the patient is mobilised within a few hours, minimising the risk of re-tethering. In cases following segmental fusion or total disc replacement where the implant is causing the posterior wall of the disc to bulge and compress the nerve, the nerve can first be mobilised and displaced, the false bulge can then be removed and the nerve restored to its natural symptomless position.
Why is this better than conventional surgery?
This diagnostic and treatment pathway seeks out the single level responsible for the pain or loss of function and is in contrast to conventional surgery. The conventional surgeon, especially where multi-level conditions are suspected, will treat all the involved levels with ‘overkill’ multi-level surgery with unnecessary exposure to the problems of blood loss, potential nerve and tissue damage, extended post-operative care and unnecessarily operated upon non-causal levels. Minimally invasive techniques can be used in all age groups but offer treatment for the frail, the infirm and the elderly because they avoid the use of General Anaesthesia. They also open up the opportunity to treat long term symptoms where the diagnosis is in question to the conventional surgeon and where the patient is otherwise referred for palliative Chronic Pain Management.
What proof is there of successful treatment?
Aware State Diagnosis and ELDF Surgery are delivering encouraging results in well over 80% of patients when reviewed 2-4 years later, and 70% at 10 years later. In a current study of Failed Fusion Surgery the success rate has been 80% at three years.