What Is Failed Back Syndrome?
I see lots of patients with failed back syndrome. What’s that? Why does it happen? How can it be treated? Let’s dig in.
What Is Failed Back Syndrome?
Back surgery is unique in medicine in that many people know someone who has had it, and it either didn’t work or they got worse. When that happens, the medical term is “failed back syndrome”. Basically, this is just a way of saying that the surgery failed to achieve its goal. There are a number of reasons that back surgeries fail, so let’s dig into those things.
What Causes Failed Back Syndrome?
Failed back syndrome can have many causes, but most of what causes this issue can be broken done into the following categories:
- Adjacent Segment Disease
- Iatrogenic Instability
- Scarring Around Nerve Roots
- Damage to Key Structures
Adjacent Segment Disease
Adjacent segment disease (ASD) is a negative consequence of a low back fusion. Remember that fusion works by bolting together two vertebrae so they no longer move. However, when you do that, the forces that are supposed to be handled by that level get transferred to the levels above and below. In some patients, that leads to those levels getting excessive wear and tear and developing problems of their own. See my video below to learn more:
“Iatrogenic” merely means that the problem was caused by medical care. In this context, that means that the surgery caused “instability”. What’s instability? The low back bones stack on top of the other and they must be stabilized with ligaments (which act like duct tape) and muscles (which allow motion while keeping these bones aligned). All of that stability is needed because if bones move too much, they can damage joints and tweak spinal nerves.
How can surgery cause instability? First, a portion of the stabilizing facet joint is usually removed when the surgeon performs a laminectomy. This causes that level to move too much (become unstable). The surgery can also damage the stabilizing muscles called multifidus. To learn more about how those muscles work, see my video below:
Scarring Around Nerve Roots
The medical term for this is called “perineural fibrosis”. This means that the spinal nerves around the surgery site get scarred down. This is a problem as nerves normally work like Chinese finger traps so they can easily stretch and move. When they’re scarred, they don’t move well and the nerve can get tugged on with motion and become irritated. In addition, the nerve can also get constricted by the scarring. This is a problem because chemicals need to be transported down the nerve to keep it healthy, so having an area of constriction is like stepping on a garden hose which doesn’t permit the water to flow normally.
Damage to Key Structures
Realize that surgery is damage to accomplish a goal. Hence, there really is no way to open a tunnel to where you need to be in the spine without damaging the stuff along the way. What can get damaged?
- The muscles. Based on the research, this is directly related to retractor time. Meaning a retractor is a surgical instrument used to move tissues out of the way. The longer it’s used, the more damage happens to the underlying muscles.
- The spinal nerves. These days, surgeons use sophisticated tools to look for possible nerve damage or pressure during surgery, but injured nerves still sometimes happen.
- The fascia. We’ll examine this one more below.
An Example of Failed Back Syndrome
This is a patient who I saw in the clinic who had low back surgery many years ago at L4-L5 and L5-S1. While some things were better, others were worse. The diagnosis after the procedure, based on the MRI, was scarring around the L4 nerve root. However, that didn’t really explain her left-sided low back pain which has gotten worse over time.
What does this show? The left side of the MRI image (below) shows that the fascial covering of the back muscles was damaged by the surgery (yellow triangles both on the MRI and the ultrasound above). This is from the surgeon making that tunnel to perform the surgery. Why is that important? The fascia has to tightly bind muscles to allow them to work efficiently. This is also right where the patient still has pain.
The other issue here shown in the yellow oval is that the back muscles (dark in this MRI image) have been killed off by the retractor. So that means difficulty with both bending forward (these muscles help the spine get straight again after flexing forward) and stability of the individual backbones. So what can be done about all of these problems?
How Do You Treat Failed Back Syndrome?
Treatment obviously depends on the cause, but the good news is that, in my clinical experience, another surgery is rarely needed. Here are the traditional (often surgical) and more advanced and less invasive ways to treat these conditions:
- Adjacent Segment Disease:
- Traditional: Fusion surgery for the next level up or down or both. This of course just means that the next levels left unfused are more likely to need more fusion surgeries down the road.
- Advanced: Use platelet based therapies delivered with precise x-ray guidance to tighten ligaments above and below the fusion and inject products which will help those levels resist the damage.
- Iatrogenic Instability:
- Traditional: Add a fusion to the level that’s unstable. The problem? See adjacent segment disease above.
- Advanced: Tighten ligaments with precise injections, see above.
- Scarring Around Nerve Roots:
- Traditional: Few good options outside of more surgery to remove the scar tissue which in and of itself may cause more scarring.
- Advanced: Use a growth factor rich platelet lysate to carefully hydro-dissect around the scarred nerve and break up the scar tissue while leaving behind growth factors that can heal the nerve.
- Damage to Key Structures:
- Traditional: The treatment depends on what’s damaged, but there are no traditional options for most of these areas of damage.
- Advanced: Use various orthobiologics to help heal these damaged areas. To learn more about what those are, see my video below:
The upshot? Failed back syndrome is a real problem, but the solutions don’t have to involve more surgery. There are less invasive ways out of this new pain.