Back Surgery Scar Tissue – Problems and PreventionBack surgery for conditions such as spinal stenosis or degenerative disc disease usually involve some degree of scarring after the operation. There is considerable debate over the relevance of this scar formation to Failed Back Surgery Syndrome, with a review by Waguespack (et al, 2002) finding inadequate decompression to be the major cause of FBSS. Only 9.3% of cases were attributed to neuropathic causes such as scarring after back surgery. Indeed, some patients with evidence of scarring suffer no back pain or radicular pain after surgery (Rönnberg, et al, 2008). Numerous other studies have found wildly varying degrees of FBSS induced by scarring, with some blaming epidural fibrosis for 25% of cases and others claiming that psychological factors such as job dissatisfaction are the cause of chronic back pain after surgery (Gasiński, et al, 2000, Mielenz, et al, 2008).
Scar tissue after back surgery can however cause further leg or back pain. Peridural fibrosis may cause pinched nerves in much the same way as spinal stenosis would. Surgery to remove the scar tissue may be necessary but could result in further scarring itself and the risk of FBSS being caused by peridural fibrosis jumps to 60% after a subsequent operation (Waguesprack, et al, 2002). Most scarring occurs within three months of surgery, and a patient may find that their back pain is relieved initially by surgery only to be replaced by increasing pain due to the formation of scar tissue. If improvement is felt over the first three months after surgery then improvements will usually continue. If no improvement is experienced after three months then the outcome is usually poor for pain reduction but may not be due to scarring.
Preventing Scar Tissue after Back Surgery
Fibrosis, or scar formation, is a natural response by the body to trauma such as back surgery. This does not however mean that it remains unproblematic and recurrent back pain is often dependant on the type and degree of scarring after back surgery. Surgeons are devising ways of reducing the degree of scarring after surgery such as laminectomy, discectomy, and fusion with the development of membranes and barrier-gels that prevent the adhesion of fibrous scarring to nerves. Autologous fat transfer and mesh inserts have also been used with varying degrees of success although the most beneficial intervention appears to be avoiding excision of the ligamentum flavum where possible (Ozer, 2006).
Some exercises can help to reduce scarring after back surgery and prevent the entrapment of nerve roots by adhesions. Physical therapy should be part of the rehabilitation regime for anyone undergoing back surgery as too much too soon, and too little too late can both prevent an optimum recovery. Regaining general mobility quickly after surgery can limit the opportunity for scar tissue to form around the nerve and walking and non-weight-bearing exercise is recommended for most patients by their physician after their operation. Stretching out your lower limbs keeps the nerves in the lower back mobile and fibrous scarring is broken up leading to improvements in flexibility.
There is hope that a drug called mitomycin C may offer benefits in reducing scar tissue formation in patients undergoing back surgery with animal trials showing promise. Unfortunately, the trials in human patients found no similar benefit and researchers are now looking at altering the dose, administration, and duration of treatment to observe the effects (Suat, 2008). Laser spine surgery may also be a minimally invasive option to remove scar tissue that has become problematic. Surgery is usually the last resort, however, and should not be relied on as a guaranteed method of pain reduction.
Other Scar-Reduction Options after Back Surgery
Smoking is a major risk factor for any patient undergoing back surgery, particularly where a fusion procedure is to take place. This is because the rate of successful union diminishes rapidly with cigarette use before and after surgery as nicotine and other chemicals in the tobacco inhibit the formation of new bone. In addition to the effects on the newly growing bone, smoking also adversely affects circulation, meaning that oxygen and nutrients may not be delivered in sufficient quantities to supply an adequate recovery. Smoking also decreases the body’s stores of vitamin C which is important in the production of collagen, a structural protein involved in scar tissue formation. Cadmium in tobacco can lower zinc levels which affects protein formation and enzyme activity, along with immune system regulation. Faulty immune responses can increase inflammatory substances in the body and this, combined with poor protein synthesis, may encourage abnormal scar tissue formation leading to nerve compression.
Patients are advised, therefore, to quit smoking well ahead of any back surgery, then remain hydrated and well nourished both before and after their back operation, and to thoroughly engage in an appropriate physical therapy regime. All of these activities can reduce the risk of problematic scar tissue formation and the likelihood of Failed Back Surgery Syndrome.
Ozer AF, Oktenoglu T, Sasani M, Bozkus H, Canbulat N, Karaarslan E, Sungurlu SF, Sarioglu AC., (2006), Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery, Neurosurgery. 2006 Jul;59(1 Suppl 1):ONS126-33.
Rönnberg K, Lind B, Zoega B, Gadeholt-Göthlin G, Halldin K, Gellerstedt M, Brisby H., (2008), Peridural scar and its relation to clinical outcome: a randomised study on surgically treated lumbar disc herniation patients, Eur Spine J., Vol.17, No.12, pp.1714-20.
Suat E. Çelik, MD, et al., (2008), Mitomycin Protection of Peridural Fibrosis in Lumbar Disc Surgery, Journal of Neurosurgery: Spine, Vol. 9. No. 3. ppp. 243-248