Back surgery is far from a simple process and when back surgery goes wrong it can have devastating consequences for patients and their families as demonstrated by recent reports on the aftermath of back surgery involving Medtronic’s Infuse device. Failed Back Surgery Syndrome (FBSS) is a name given to the condition of chronic pain after spinal surgery, but there are other things that can go wrong with back surgery and, as such, FBSS is a general catch-all for post-operative problems. Where back surgery fails to relieve neck, back, or leg pain it is deemed a failure, but spinal surgery resulting in permanent nerve damage and paralysis is also placed under the heading of FBSS. The frequency with which back surgery is carried out is, perhaps, the reason why a condition has been described for surgical failure. After all, no term exists for the failure of cardiac surgery or brain surgery.
Causes of Back Surgery Gone Wrong
When back surgery goes wrong it can be for many reasons, some controllable and some beyond our control. Patients may be misdiagnosed and operated on erroneously; back pain associated with a disc herniation at one level may, in fact, be caused by nerve impingement elsewhere in the spine. Back surgery may also fail because the post-operative period is compromised by the patient smoking, engaging too soon in physical activity (or too late), and even by accidental injury such as a fall or trauma.
Complications during spinal surgery are another cause of failed back surgery; whenever the body is opened up there is a risk of blood loss, infection, and in the case of spinal surgery, the possibility of nerve damage. Scarring can also cause FBSS, with suitable physical therapy often helping to prevent nerve adhesion and epidural fibrosis. Patients undergoing repeated back surgeries are at an increased risk of FBSS as scarring is increasingly likely to occur and cause symptoms such as back pain, paraesthesia, or numbness.
Surgical Error and Recurrent Herniation
Recurrent disc herniation may be the factor behind back surgery gone wrong, especially when a patient undergoes a spinal fusion that then places added pressure on the adjacent segments of the spine. In the recovery period following back surgery a patient, and their physician, may mistake back pain for a post-surgical symptom rather than a sign of further problems. Minimally invasive back surgery decreases the risk of such a mistake being made as the recovery period is usually quite short and so any new symptoms arising can be considered in and of themselves rather than as necessarily connected to the earlier issue or the back surgery just completed.
Failure to Free Trapped Nerves
Patients with pinched nerves in the spine may also experience problems after back surgery if the procedure did not adequately remove all of the offending material. The small spaces in the spine make it particularly hard to visualize obstructions from osteophytes, herniated disc material, and/or scar tissue which may mean that some of the substance pressing on a nerve or causing irritation on movement remains even after surgery. Minimally invasive procedures, such as a microlaminoforaminotomy, face a higher risk of leaving errant material behind to cause irritation but they do have the advantage in some cases of being done under local anaesthetic so that the surgeon can actually ask a patient about changes in sensation and assess the success of the back surgery before closing the incision.
Too Much too Soon after Back Surgery
Some patients experience difficulties after back surgery because they are simply out of condition after a prolonged period of disability coupled with convalescence. A sudden relief of pain may prompt some to become very active too quickly which may jolt hardware in the spine (if used), cause scarring of tissues in the back, or simply strain muscles that have become weak by a sedentary lifestyle prior to back surgery.
Common causes of back surgery gone wrong include pre-existing conditions such as diabetes, circulatory problems, and autoimmune conditions and diseases that affect the joints or nerves, such as fibromyalgia, multiple sclerosis, lupus, and rheumatoid arthritis. Ensuring that the patient is adequately prepared for back surgery and its consequences is key to ameliorating the risk of failed back surgery syndrome. Pre- and post-surgical guidelines around smoking and nutrition, along with exercise and medications, are put in place to promote the best possible outcome for patients undergoing back surgery. These are revised as new information becomes available and tailored to the individual patient where possible.
Deciding if it’s Failed Back Surgery Syndrome
Patients who experience sharp pain, dull back ache or leg ache, paraesthesia, numbness, or muscle weakness after back surgery may be experiencing FBSS. In some cases a tingling and warm sensation in the hands or feet may actually indicate the revival of a nerve damaged prior to surgery and pain and altered sensations can occur as the nerve repairs itself now it is no longer compressed. Where no relief of back pain or other symptoms is experienced in the first three months following spinal surgery the procedures is usually considered a failure and patients often endure further diagnostic testing and even more back surgery.
Signs of improvement usually indicate successful back surgery and an increased likelihood of symptoms continuing to get better. After a year, patients who have not improved from nerve damage are unlikely to experience symptom relief as the nerves would have begun to heal by this time.
Whilst recent revelations about the improper use of Medtronic’s Infuse device in spinal surgeries has been capturing headlines and raising patients’ concerns, the chances of back surgery going wrong have not changed substantially in recent years. Patients are still advised to put off most surgery for as long as possible where conservative treatments continue to provide relief. Ensuring that patients understand the risks of back surgery and its potential to make back pain worse is a key aspect of pre-surgical care that should not be overlooked. When back surgery goes wrong it can be devastating and patients need to weigh up the risks against the benefits in pain reduction before proceeding with any spinal operation.