Why Back Surgery Often Fails: The Neuro-Chemo-Mechanical Model
This past decade, a curious thing began happening that is a nascent mega-trend that’s still changing medicine. Most spine surgeons have yet to notice it, but some do. What’s the trend? There has been a distinct shift away from spine surgery toward less invasive care. This shift will eventually reshape an industry with tens of billions in revenue. Let’s dig in.
Why We All Know Back Surgery is a Problem
There is no other medical procedure that has as much bad word of mouth as back surgery. In fact, patients who are worse after back surgery have become an urban legend of sorts. It’s something that we all recognize at some level.
For example, if you’re at a party or just talking to a relative when the topic comes up, we all instinctively know that this is a procedure laden with problems. Why? Because we all know or have some connection to someone who has been disabled by back surgery.
Why does this happen? Because not only are there bad results, but also surgeons generally won’t own their bad results. I have had more instances than I can count where a patient comes in with more problems after back surgery. I ask if they brought this up with the surgeon. They state yes, but the surgeon looked at the x-rays and said everything was fine and that their job was done.
Why Does Back Surgery Fail?
Back surgery fails because surgeons have used a model to understand back pain that is way too simplistic. These principles can be distilled into just a few statements:
- The solution for instability is a Fusion.
- You can fix nerve pain by removing tissue and opening the area up.
- You can realign the spine to get rid of the pain.
All of these simple ideas can be couched in very complex medicalese, but they’re still simple ideas. In fact, let’s look at why they’re overly simplistic, which is one reason back surgeries fail so darn often.
The solution for instability is a Fusion.
Instability in the spine is a major issue. That means that due to trauma or just degenerative disease, certain segments in the spine move too much. This can lead to damaging the facet joints, irritating the spinal nerves, and other issues. Hence, as a general principle, reducing instability is a net positive. However, the way surgeons approach this is to fuse the area, which means that hardware is added so that this spot no longer moves at all. This then causes the adjacent structures to get mechanically overloaded and in many patients, these levels then begin to fail, which is called Adjacent Segment Disease (1). Hence, this is a caveman conceptualization of a problem and solution. Or said another way, fixing one issue while causing another.
You can fix nerve pain by removing tissue and opening the area up.
In the spine, discs, arthritic bone spurs, and swollen ligaments can press on and irritate nerves. The surgical solution here is also simplistic-just cut out the offending part. Hence, we see surgeries like Discectomies where a part of the disc is surgically removed. That, however, weakens the remaining disc tissue and can lead to a recurrent disc bulge or herniation (2). Or we see a Laminectomy where the roof of the spinal canal is removed and often the inside part of the facet joint. However, that can lead to instability as discussed above, scarring, and huge amounts of damage to the muscles that stabilize the spine (4).
You can realign the spine to get rid of the pain.
Again, here is a concept that has a kernel of truth, but the surgical solution has issues. In this case, the spine is bent sideways (Scoliosis) or one vertebra is out of whack forward or backward, or there isn’t a normal curve. These are all legit issues that can cause overload and pain. However, the surgical solution is to install rods and screws and fuse the area into a normal shape and alignment. However, that has all of the same issues as the Fusion above.
The Bull in the China Shop
As discussed above, each surgical solution has serious issues, because all cause irreversible damage to accomplish a goal. Even inserting artificial discs which were supposed to allow normal motion have the same issue. You can’t insert one without damaging the spine. In addition, once one is in place, it seems to overload the adjacent segments of the spine just as if a Fusion was performed (3). Meaning, regardless of what you do surgically, you are damaging the spine in hopes that the damage you cause is less of a problem than the good you do.
The Neuro-Chemo-Mechanical Model
One of the things that surgeons generally fail to understand is that they have only 1/3 of the actual calculus that defines pain in the spine. These are:
- Neurologic status (upregulation, irritation)
- Chemical (inflammatory chemicals)
Surgeons are all about the mechanical part of the equation. However, many studies confirm what we see every day in the clinic-MRI findings, and pain are often not correlated (5). For instance, the spine can look like a bomb went off and some people have little pain. In addition, it also goes the other way, the spine can look not bad on MRI and people are legitimately disabled. Why?
There are two other two parts of the spinal pain equation that surgeons ignore. One is “pissed off” nerves (upregulation, irritation) and the other are the nasty chemicals that surround them or other structures. For example, a disc herniation in a patient that has low systemic inflammation is a short-lived episode of pain, but that same exact herniation in someone who has high levels of an inflammatory chemical in their body is a 6 month disabling and life-altering problem (6).
The Shifts in the Wind About to Become a Hurricane
Because spine surgeons are so fixated on only part of the problem and the results have been bad enough that back surgery failure has become an urban legend, some patients have been slowly moving from the surgery column to non-surgical therapies. Even a decade ago these other options like orthobiologics (precise injections to help these issues) were few and far between. However, today they’re becoming much more common. All of this is slowly pulling patients out of spine surgery practices. The key part that will make this shift in the wind a hurricane is insurance coverage, something we’ve been working on for years and are slowly chipping away at. Hence, in a decade, my prediction is that traditional spine surgery rates will decline by half or more. For more information on how we approach these issues, see my video below:
To address this issue, we see spine surgeons hiring non-surgeons. However, this is an inherent conflict of interest. Meaning, to move all the patients that can be treated non-surgically out of the surgery column, the doctor has to be independent of a spine surgery practice. Their incentive needs to be in the direction of non-surgical care without pressure from surgical partners.
Is Surgery Still Needed?
The short answer is Yes. There are still times that surgery is the best option for someone. However, my current best estimate is that at least half to 2/3rds of the spine surgery currently performed to treat pain will go away over the next decade-plus.
The upshot? Back surgeries fail often enough that it’s become an urban legend we all recognize. Meaning when you talk to someone who had back surgery and they’re still in pain, we all have a sense that this is a common occurrence. There are reasons why this happens. There are also reasons why many patients are choosing to look at different alternatives to solve their back pain.
(1) Tobert DG, Antoci V, Patel SP, Saadat E, Bono CM. Adjacent Segment Disease in the Cervical and Lumbar Spine. Clin Spine Surg. 2017 Apr;30(3):94-101. doi: 10.1097/BSD.0000000000000442.
(2) Shepard N, Cho W. Recurrent Lumbar Disc Herniation: A Review. Global Spine J. 2019;9(2):202-209. doi:10.1177/2192568217745063
(3) Saavedra-Pozo FM, Deusdara RA, Benzel EC. Adjacent segment disease perspective and review of the literature. Ochsner J. 2014 Spring;14(1):78-83. PMID: 24688337; PMCID: PMC3963057.
(4) Daniell JR, Osti OL. Failed Back Surgery Syndrome: A Review Article. Asian Spine J. 2018;12(2):372-379. doi:10.4184/asj.2018.12.2.372
(5) Vagaska E, Litavcova A, Srotova I, Vlckova E, Kerkovsky M, Jarkovsky J, Bednarik J, Adamova B. Do lumbar magnetic resonance imaging changes predict neuropathic pain in patients with chronic non-specific low back pain? Medicine (Baltimore). 2019 Apr;98(17):e15377. doi: 10.1097/MD.0000000000015377. PMID: 31027128; PMCID: PMC6831323.
(6) Schistad EI, Espeland A, Pedersen LM, Sandvik L, Gjerstad J, Røe C. Association between baseline IL-6 and 1-year recovery in lumbar radicular pain. Eur J Pain. 2014 Nov;18(10):1394-401. doi: 10.1002/j.1532-2149.2014.502.x. Epub 2014 Apr 2. PMID: 24692238.