Failed Back and Neck Surgery Syndromes happen when a surgery to correct pain completely fails to alleviate the pain and in some cases makes the pain worse. There are many reasons why a surgery could fail to provide results, both related to the patient and the surgeon. How is it that a patient could cause a surgery to fail. A great example of this would be that a patient has undergone a spinal fusion to correct spinal instability in the lower back. The surgeon has advised the patient that smoking cigarettes which could severely reduce the healing chances and effect the fusion process. The patient ignores the doctor and continues to smoke and the fusion doesn’t heal. This is an example of the patient being at fault. In what ways could a surgeon be at fault? There are many times that there is fault before the surgery is even performed. If there is an inaccurate diagnoses the surgery will be performed in the wrong area, and possibly the wrong surgery will be done. It is important to seek a second opinion of a specialist before proceeding with surgery of any kind. If two heads can agree on what and where the problem is, it is likely that there will be an accurate diagnosis. One of the most common reasons for Failed Back and Neck Surgery Syndrome is that the surgeon is just not experienced enough in the technique being performed and he/she doesn’t perform it properly. This is why it is important to ask the right questions to the surgeon before moving forward with the surgery. How long have you been performing back surgeries? How long have you been performing this specific surgical procedure? and how many times a year do you perform this surgery. Back and neck surgeries are procedures meant to be a permanent fix for a specific problem and correcting failed back or neck surgery is difficult. Human spine is a complex structure that provides both mobility (so to bend and twist) and stability (so to remain upright). The normal curvature of spine has an “s”- like curve when looked at from the side. This curvature allows even distribution of weight and with stand stress.

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Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
drsandeep123@gmail.com
www.drsandeepagrawal.com
www,agrasenortho.com
Failed Back Surgery Syndrome(FBSS)
SYNOVIAL CYST

2. FBSS
• Failed back surgery syndrome
Numbers of spine surgery increasing
!
Surgical results not always successful

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Failed Back Surgery Syndrome
FBSS is a term applied to a heterogeneous group of
individuals who share only one characteristic - continued
back and/or extremity pain following one or more spinal
operations
15% of patients will experience persistent or recurrent
symptoms
Spectrum of abnormalities ranging from purely organic
to purely psychological, but in most cases consists of a
physiological abnormality complicated by psychological
factors
FBSS is perhaps the prototypical example of chronic
pain as a biopsychosocial disorder

4. Failed back surgery syndrome
• Definition: the results of re-operation did not differ
significantly from those of initial surgery
!
• Etiology:
– Recurrent disc herniation
– Segmental instability
– Spinal stenosis
– Infection

5. Failed back surgery syndrome
• No improvement
• Getting worse
• Recurrence after a period of pain relief
!
• Wrong diagnosis
• Inadequate treatment
– Wrong level or side
– Inadequate decompression or stabilization

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Failed Back Patient Profile
Pain and suffering often disproportionate to any
identifiable disease process
Depression
Physical deconditioning
Inappropriate use of physician-prescribed medications
Superstitious beliefs about bodily functions
Failure to work or perform expected physical and
cognitive activities
No active medical problems that can be remediated with
the expectation of relief of pain

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The “Ds” of FBSS
Disuse
Deconditioning
Drug misuse
Dependence
Depression
Disability

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9% – 28% of the
population suffers from
moderate to severe chronic
non-cancer pain
American Pain Society
(2002); Chronic pain in
America: roadblocks to relief
Chronic Pain – Scope of the Problem

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Pain Types
NOCICEPTIVE PAIN
results from ongoing activation of mechanical, thermal, or chemical nociceptors
typically opioid-responsive
eg. pain related to mechanical instability
!
NEUROPATHIC PAIN
spontaneous or evoked pain that occurs in the absence of ongoing tissue damage
typically opioid-resistant***
eg. pain secondary to nerve root injury

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Neuropathic Pain
Pain in absence of ongoing tissue damage
Pain in an area of sensory loss
Paroxysmal or spontaneous pain
Characteristics of pain: burning, pulsing, stabbing
Allodynia, hyperalgesia, or dysesthesias
Delay in onset following injury
Presence of major neurological deficit
Poor response to opioids

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Biopsychosocial Model of Pain
Pain Behavior
Suffering
Pain
Nociception

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Failed Back Surgery Syndrome
Surgical Complications
Disk space infection
Iatrogenic instability
Nerve root injury
Retained disk fragment
Recurrent disk herniation
Inadequate decompression
Complications of fusion and instrumentation
Adhesive arachnoiditis

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CLASSIFICATION OF FAILURE
■ No improvement immediately after surgery
with outright failure to improve mono- or
polyradiculopathy
1) Wrong pre-operative diagnosis
2) Technical error

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■ No improvement immediately after surgery
with outright failure to improve mono- or
polyradiculopathy
1) Wrong pre-operative diagnosis
1) Tumor
2) Infection
3) Metabolic Disease
4) Psychosocial
5) Discogenic pain (IDD,IDR)
6) Decompression done too late for disc
sequestration
CLASSIFICATION OF FAILURE

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CLASSIFICATION OF FAILURE
■ No improvement immediately after surgery
with outright failure to improve mono- or
polyradiculopathy
2) Technical error
1) Missed level or levels
2) Failure to perform adequate decompression
1) Missed fragment including foraminal disc
2) Failure to recognize canal stenosis
3) Conjoined nerve root

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Failed Back Surgery Syndrome
Physician Decision Making
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection

17. Problems of re-operation
• Poor landmarks of anatomy
• Wrong level
• Neural injury
• Blood loss
• Longer op time
• Difficulty in instrumentation
• Inadequate bone graft

18. F.B.S.S.
History taking
Neuro. exam
Image study
Psychosocial evaluation
Specific diagnosis
Mechanical causes Non-mechanical causes
Appropriate surgery
Medical tx
Rehabilitation
Psycho. tx

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Most common cause of failed
back syndrome is poor
judgment on the part of the
physician. Surgery prescribed
as a last resort, with a hope
and a prayer that it might
alleviate the pain.

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CLASSIFICATION OF FAILURE
!
■ Temporary relief but recurrence of pain
1) Early recurrence of symptoms (within weeks)
1) Infection
2) Meningeal cyst
3) Juxtafacet cyst
1) Synovial cyst
2) Ganglion cyst

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JUXTAFACET (JFC) CYSTS :
■ Term originated by Kao
et al in 1974
■ First reported by von
Gruker in 1880 during
autopsy
■ First diagnosed clinically
in 1968
CYSTS ADJACENT
TO THE FACET
JOINT, OR ARISING
FROM THE
LIGAMENTUM FLAVUM
Kao C.C., Winkler S.S., Turner J.H: Synovial Cyst of Spinal Facet. J
Neurosurg 41:372-6,1974.
Kao C.C., Uihlein A., Bickelr W.H: Lumbar Intraspinal Extradural Ganglion
Cyst. J Neurosurg 29:168-72,1968.

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TYPES
■ SYNOVIAL CYSTS
(those having a synovial
lining membrane)
■ GANGLION CYSTS
(those lacking lining
membrane)

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ETIOLOGY
Unknown
Possibilities
Synovial fluid extrusion from the joint
Latent growth of a developmental rest
Myxoid degeneration and cyst formation in
collagenous connective tissue
Increased motion plays a role in some
cases

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IMAGING
PRE OPERATIVE TI
8 WEEKS POST OP T1
SYNOVIAL CYST
SYNOVIAL CYST

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IMAGING
PRE OPERATIVE T2 8 WEEKS POST OP T2
HYPERTOPHIED LIGAMENT
STENOSED LATERAL RECESS
HYPERTOPHIED JOINT
DECOMPRESSED CANAL
SYNOVIAL CYST

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CLASSIFICATION OF FAILURE
!
■ Temporary relief but recurrence of pain
2) Mid-term (within weeks to months)
■ Recurrent disc prolapse
■ Battered root
■ Arachnoiditis
■ Patient expectations

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Battered root syndrome
The permanent radiculopathy caused by surgical trauma
was first called the battered root problem by Bertrand in
1975. It is the reappearance of radicular pain after the
relief of sciatica by operation. The pain is constant,
burning, increased by motion or Valsalva. At that time
rhizotomy was suggested as the treatment. Since it is
considered now as a type of peripheral neuropathy, the
treatment shifted to spinal cord stimulation (SCS).
!
Bertrand G. The battered root problem Orthop Clin North Am. 1975 Jan;6(1):305-10

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Arachnoiditis
Arachnoiditis is a disease of the spine which
results in the clumping or sticking of nerve roots
together inside the spinal fluid. The nerves
adhere together therefore the technical name of
the condition is "adhesive arachnoiditis".
Arachnoiditis occurs
intradurally whereas
peridural fibrosis occurs
extradurally in the epidural
space.

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Arachnoiditis
The most common causes of arachnoiditis are meningitis, spine
surgery and trauma.
A cause for which there are a few case reports in the literature are
epidural steroid injections . Epidural analgesia not cause.
The incidence of arachnoiditis after spine surgery in patients
undergoing re-operation for pain
ranges from 3.5% to 16%
Ribeiro C, Reis FC Findings and outcome of revision lumbar disc surgery J Spinal Disord 1999 Aug;12(4):287-92 and
Lumbar arachnoiditis Acta Med Port 1998 Jan;11(1):59-65.

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CLASSIFICATION OF FAILURE
!
■ Temporary relief but recurrence of pain
3) Longer-term failures (within months to years)
1) Recurrent stenosis or development of lateral
stenosis from disc space collapse
2) Instability

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Disc space collapse
A number of relapses are due to disc space collapse.
Although the disc height is often decreased in the
preoperative patient with a herniated nucleus pulposus,
it is an exceedingly common occurrence following
surgical discectomy.
Disc space narrowing is very important in terms of
decreasing the size of the neural foramina and altering
facet loading and function.
The entire process predisposes to the development of
hypertrophic changes of the articular processes.
Hanley EN, Shapiro DE. The development of low-back pain after excision of a lumbar disc. J Bone Joint Surg 1989;71A:719-721
Schneck CD. The anatomy of lumbar spondylosis. Clin Orthop 1985;193:20-37. .

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Evaluation of the Patient with FBSS
Detailed pain history including prior treatments and
MOST IMPORTANTLY the outcome of each
!
Obtain appropriate imaging studies (including those
on which surgical decisions were based)
!
Attempt to establish the underlying cause of the
pain; however……….

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Pain History
Where is it located?
Does the pain radiate?
When did it start and under what circumstances?
What is the quality of the pain?
What is the severity of the pain (VAS scores)
What factors make it worse?
What factors make it better?
Are there associated symptoms?

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Pain History
Effect of pain on sleep
Medications taken for pain
Health professionals consulted
Patient’s beliefs concerning the cause of pain
Expectations of outcome of treatment
Family expectations
Pain reduction required for “reasonable activities

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Treatment History
What therapies have been tried and what were the
outcomes?
Physical therapy
Injections
▪ Epidural steroids, nerve root blocks, facet blocks, etc
Medication history
What drugs?
Dose?
How long?
Effect?

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Imaging Studies
Static plain radiographs
Spinal alignment
Flexion/extension views
Instability
Computed tomography (CT)
Bony surgical defects
Hardware placement
Fusion mass
Magnetic resonance imaging (MRI)
Soft tissue and neural structures
Radionuclide imaging
Technetium99 bone scan
Indium111 WBC scan

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Post-operative Causes of Back Pain
Deconditioning Trauma
Muscle spasm Wrong level fused
Myofascial pain Insufficient levels fused
Spinal instability Pseudomeningocele
Diskogenic pain Graft donor site pain
Facet arthropathy Psychosocial factors
Infection
Pseudarthrosis
Loose hardware
Arachnoiditis

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Post-operative Causes of Leg Pain
Retained disk fragment Arachnoiditis
Recurrent HNP Synovial cyst
Far lateral disk Root sleeve meningocele
Lateral recess stenosis Loose hardware
Inadequate decompression Facet fracture
Wrong level decompressed Psychosocial factors
Nerve root injury
Retained foreign body
Epidural fibrosis

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Goals of Chronic Pain Management in Patients
with FBSS
Functional improvement
Functional improvement
Functional improvement!!!
Improvement in physical activities and exercise tolerance
Reduction in narcotic use
Reduction in healthcare consumption
Return to work
Pain reduction

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Common Features of Multidisciplinary Pain
Management
Physical therapy and rehabilitation
Medication management
Patient education about pain and body function
Psychological treatments
Coping skills training
Vocational assessment
Therapies targeted toward improving the likelihood of
return to work
Surgical interventions for selected patients

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Multidisciplinary Pain Clinic Personnel
Physicians
Neurosurgeon
Orthopedic surgeon
Anesthesiologist
Neurologist
Physiatrist
Internal medicine
Psychiatrist
Addictionologist
Nurses
Psychologists
Physical Therapist
Occupational Therapist
Vocational counselor
Social worker
Dietician
Recreational staff
Administrative support staff

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Electrophysiological Studies
EMG is likely of greater utility in FBSS than
in primary low back pain and sciatica
!
Greatest use is for establishing the presence of
a peripheral neuropathy
!
May be helpful for defining a feigned
neurological deficit
!
Rarely using in decision-making regarding
treatment

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Diagnostic Blockade
Rationale is straightforward
In practice, it is much more
complicated
Specificity may be low
Single blocks (positive or negative)
have a high error rate
Placebo controls provide the most
accurate information
Multiple blocks using different
agents
BLOCKS ARE ADJUNCTS AND SHOULD NEVER BE
SUBSTITUTED FOR SOUND CLINICAL JUDGEMENT !

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Facet Block
Blockade of the innervation of the facet joint will relieve
pain in some patients with facet disease

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Facet Block
Rarely useful in patient with
FBSS
Transitional facet disease
above a fused level
!
Anatomy obliterated and
accurate block not possible
!
Blockade of pseudarthrosis may
sometimes be useful

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Selective Nerve Root Block
Must be done accurately to provide any useful
information
!
One root at a time
!
Small volume of local anesthetic without
steroids
!
Confirm the presence of an adequate block
!
Confirm findings on repetitive blocks

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Anticonvulsant Agents (AEDS)
Similarities in pathophysiology of neuropathic pain and
epilepsy
!
All AEDS ultimately act on ion channels
!
Efficacy of AEDS most clearly established for neuropathic
conditions characterized by episodic lancinating pain
!
Most clinical studies have focused on DPN and PHN
!
Use of AEDS in patients with FBSS is nearly entirely empiric

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Antidepressant Analgesics
Relieves all components of neuropathic pain
!
Clear separation of analgesic and
antidepressant effects
!
Although other agents (eg anti-epileptics))
may be regarded as 1st line therapy over
antidepressants, there is no good evidence for
this practice
!
More selective agents are either less effective
or not useful (serotonergic, noradrenergic)

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Corticosteroids
Useful in the short term for treatment of radicular pain
!
Limited role in the long-term treatment of FBSS
!
Epidural or transforaminal steroids for selected patients
Cochrane Review (Nelemans, et al., 2002)
Most trials included patients with radicular pain
No significant difference in pain relief after 6 weeks or 6 months between ESI and
placebo

52. Adjacent instability( Case )
• Well-defined spondylolisthesis
• Dynamic instability with Slippage > 4 mm
Angle change > 10° on flexion and extension views

53. Risk factors --- not clearly defined
• Implant rigidity
• Bone grafting technique
• Gender
• Age
• Decompression beyond fused
level
• Posterior complex
!
• Biomechanical factors

54. Procedures
• Decompression
– Through adjacent virgin site to stenosis
– Medial facetectomy
• Extension of PLF with autograft
• Instrumentation
– Old screws ! new screws with larger diameter
– TPS through virgin pedicles of adjacent segment

55. Best treatment is prevention
• Preservation of segmental stability during
decompression
• Avoidance of violating adjacent joint during
instrumentation
• As short fusion as possible
• Preservation of intact posterior complex

56. Results of multiple operated back is still favorable
Right diagnosis
Right patient
Right surgery
Right surgeon

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This presentation is for doctors in general.!
. Some graphics and jpeg files are taken from
Google Image to heighten the specific points in this
presentation. !
• If there is any objection/or copyright violation,
please inform drsandeep123@gmail.com for prompt
deletion. !
• It is intended for use only by the doctors of
orthopaedic surgery.!
. Views expressed in this presentation are personal.
• .For any confusion please contact the sole author
for clarification. !
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use the material best suited to him. !

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