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The Failed Back Syndrome

Failed back syndrome is a nonspecific term used to describe patients who continue to have symptoms in spite of undergoing surgery for those symptoms.  It is occasionally employed to define patients who have not had surgery, but have failed all other forms of treatment.  The majority of patients who receive this diagnosis have had more than one operation and continue to have serious symptoms of back and/or leg pain.

Reevaluation of a patient with the so-called failed back syndrome is very similar to what needs to be done with any patient with complaints of spinal pain with and without loss of function.  This has been a sub-specialty of mine for many years.  I have seen nearly 7000 patients with this diagnosis and operated upon more than 2000.  As with any of the patients with spinal pain the key to successful therapy is making a diagnosis.  That is, finding out what is wrong with the patient rather than simply applying nonspecific treatments based upon complaints.  In an extensive review of the patients who continue to suffer after surgery, I discovered that about one-third had a problem which was not relieved by the initial surgery.  Another third had developed a complication from the procedure which was causing the pain.  The final third had developed a new problem in spite of successful earlier operations.

The first goal in evaluating a patient is an accurate history with an accurate description of the pain and what makes the pain better and worse.  Success or failure of previous treatments is important to understand.  Therefore, it is extremely important that patients come with the most accurate history possible of the complaints, how they appear, how they compare to original problems and the results of all treatments, especially surgical treatments.

The physical examination is rarely diagnostic, but does describe loss of function in individual patients.

Imaging studies are key.  Plane x-rays will examine the bones well and can determine gross movements of the spine with flexion and extension.  CT studies demonstrate the bones and with appropriate computer reconstructions the artifacts introduced by metal fixators in the spine can be reduced.  That hardware can be well seen and abnormities of hardware location and spinal fusion stability can be determined.

One of the hardest things to do is to determine when a fusion is solid.  The CT is one of the more accurate ways to determine stability of fusion, but no technique guarantees to always find out whether fusion is solid or not.  The MRI is better for all the soft tissues, but metal so degrades the image that MRI may not be useful.  Many patients need a CT myelogram in which a contrast agent (dye) is injected into the spine.  This gives the best pictures of the nerves and deformities of the spinal sac, nerves, and spinal cord.

The first important issue with any patient who has failed previous surgery is why the failure occurred.  To determine this, the imaging studies are most important.  Often they show a problem which can be treated.  However, just as with less complicated spinal problems, diagnostic blocks are frequently needed to be as certain as possible about the cause or causes of the pain.  With patients who have had surgery the diagnostic blocks can be a little more complicated than in patients who have never had an operation.  This is because the possibilities for the causes of pain are more in patients who have undergone operations.  In addition to the typical blocks of joints and nerves it may be necessary to anesthetize parts of the fusion itself to determine when loose screws, breaks in the fusion (pseudoarthroses), pressure on nerves beneath the fusion, and inflammation around the hardware may be the causes of pain.  Frequently pain comes from discs above a successful fusion.  Sometimes there is residual pain from discs within a successful fusion.  Frequently pressure on nerves has not been relieved by original surgery or has developed in spite of a successful original operation.  New diseases can develop above or below a fusion.  Deformities of the spine can occur above or below previous surgery.  To determine which of these are present and important, a combination of the imaging studies and diagnostic blocks will often provide an answer.

Once the most likely causes of the pain and/or functional losses are known then specific treatment can be developed.  Sometimes these conditions will respond to treatment with blocks using the steroid medication which reduces inflammation.  Sometimes pain can be relieved by interrupting the nerves which carry pain from the same joints.  Some patients need additional surgery to correct new problems, extend the fusion, or repair a broken fusion.  New disease can develop in discs above or below a fusion requiring their replacement with additional fusions.  Sometimes nerves or the spinal canal need decompression to relieve pressure upon them.  A decision for surgery can usually be made on the basis of the severity of the symptoms and the demonstration of something which is correctable by surgery and is causing the pain.

In many patients no specific cause of pain can be found.  Then symptomatic treatment is all that is possible.  Referral to an expert in spinal stimulation is the best choice for many patients for pain relief.  Another technique for pain relief is called a drug pump.  The use of this device is based upon the fact that delivery of small amounts of narcotics into the spinal canal around the injured nerves and the part of the spinal cord they enter can achieve much better relief of pain than one gets with oral drugs.  The technique requires that a small computerized pump be placed underneath the skin and attached to a tube which has been accurately directed into the spinal canal to provide the dose of drug at the most appropriate location.  These pumps work automatically and are totally inside the body.  They do have to be filled regularly, but they can often provide good pain relief with much lower doses of drugs and hence fewer side effects.

The real key for the failed back syndrome is diagnosis.  The first thing to determine is if any repairable cause of pain can be found.  If it can, then re-operation may solve the problem.  If it cannot, management of the pain is the next important goal.

Sometimes chronic pain takes a significant toll upon patients.  Anxiety and depression are common disabling factors that occur with chronic pain.  The fact they occur does not imply that the pain is not real or than there is a significant psychological issue with the pain complaint.  These are normal responses of normal people to chronic pain.  Nevertheless, they have to be treated because they can increase pain, increase disability, and prolong the treatment process, sometimes making pain treatment impossible unless they are adequately treated.  Control of anxiety and depression with added cognitive techniques to help patients control pain can be extremely important.  There are chronic pain treatment centers which have been developed to treat depression and anxiety, withdraw patients from harmful amounts of drugs, and provide well-motivated patients with mental techniques to suppress pain.  These centers are very effective for some patients.  Especially when drug misuse, anxiety and depression are important issues, the pain treatment center may be the best option for pain relief.