By Kenneth Light, MD
Orthopedic Spinal Surgeon and Medical Director of The San Francisco Spine Center, specializing in correction of Failed Back Surgery
Almost everyone has a friend or relative who has had low back surgery, and after the operation, has never been “quite the same.” In fact, according to the American Academy of Orthopedic Surgeons, there are approximately 200,0000 laminectomies performed every year. An estimated 20% – 30% of these operations are reported to be unsuccessful. It is easy to see that the problems of “failed back surgery” are enormous. How can this happen? Are there really so many failed surgeries? Can failed surgery be avoided? Can failed surgery be corrected?
Once patients receive a diagnosis of “failed back syndrome,” they are frequently labeled as “hopeless” and ostracized not only by the medical community but also by their employers, friends and even their family. Many lose their sense of identity, purpose, livelihood and will to go on.
Most failed back operations can be avoided and are usually caused by a very well-meaning surgeon operating on the wrong patient for the wrong indication. Removal of the disc and lamina frequently makes referred back pain worse, since it precipitates further disc-narrowing and hastens the degenerative process. Laminectomy and/or discectomy is 90% effective in relieving pain radiating below the knee in patients who have failed a suitable conservative program, and are disabled by severe pain or a progressive neurologic deficit.
Microscopic discectomy for removal of extruded disc fragments can be very successful; however, this procedure sometimes results in incomplete extraction of the fragment, or recurrent disc herniation. Patients having undergone such procedures, and now having ongoing or recurrent pain, should be worked up with a gadolinium enhanced with MRI scan (75% accurate), or, if need be myelo-disco-CT scan (95% accurate) for further diagnosis. Removal of the retained or recurrent disc fragment can turn a failure into a success.
Spinal stabilization should accompany decompression for the diagnosis of degenerative or isthmic spondylolysthesis, scoliosis or recurrent L4-5 disc herniation, since ongoing leg pain commonly occurs following decompression only.
Disc removal in the cervical spine should always be accompanied by fusion with an autogenous iliac graft. Removal of the disc precipitates mechanical neck pain, with subsequent root entrapment, unless the degenerative cascade is kept in check by fusion. While fusion does place some added risk of herniation on the above adjacent segment, our 95% success rate with fusion, and our 10-year recurrence rate of less than 7% at an adjacent level more than justifies the risk.
It would take an entire volume to discuss this incredibly complicated subject. Failed back syndrome can be avoided by performing the right operation, on the right patient, at the right level. Failed back surgery is a fact, but it is fictitious to think that it cannot be avoided by better patient selection, by meticulous surgical technique and by selection of the proper operation for each specific diagnosis. Just because a patient has had a procedure that has not produced the desired result, it does not mean that all subsequent procedures will also be unsuccessful. While surgery cannot produce a perfect spine, it can turn a disabled patient into a productive member of society.