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“Failed back surgery” syndrome – who or what failed?


It’s a term I thought had died a natural death. Failed back surgery syndrome. I used to hear it in the late 1980’s when people with low back pain often had five or six surgeries to try to “fix” whatever wasn’t working in the back. I hadn’t heard it for a while and I really thought it had gone the way it should have – into that great rubbish bin diagnosis pile in the sky, along with “somatisation” and “functional pain” and trigger points. But, to my astonishment, there it is, now a separate MeSH title when you search through Ovid or Medline.

The question I always ask is “Who or what has failed?”

Is it the patient who dares to carry on saying that they have pain, sometimes even more pain than before surgery?

Is it the surgeon for choosing the wrong surgery, or perhaps for doing surgery at all?

Is it the nervous system, already sensitised, now subject to more sensitisation through the planned trauma of the surgical scalpel?

Is it the system for funding surgery?

In a paper written by Shapiro (2015), the rate of “failed back surgery syndrome” is reported as being between 10 – 40%. It seems to increase when the surgery is complex, and it hasn’t improved despite developing less invasive surgical techniques.  Shapiro goes so far as to define FBSS as  “a multidimensional chronic pain syndrome that has significant myofascial and psychosocial components that are directly related to the high incidence of lumbar surgeries in the United States.” Sorry to say, but it’s not just present in the US.

These are the psychosocial risk factors, as identified by Chan and Peng :

  • significant levels of depression,
  • anxiety,
  • poor coping,
  • somatisation
  • hypochondriasis

To be honest, I think these indications would be risk factors for ANY surgery (and probably ANY invasive procedure, including dry needling). But there’s more than this – preoperative risks such as having had prior surgery (spinal instability seems to become worse with repeated revisions); surgery carried out when imaging results suggest there may be good reason, but there is no corresponding clinical correlation; nonsurgical cases of radiculopathy and neuropathy (eg diabetes, viruses, inflammation, vascular disease). And intra-operative risks such as difficult radiographic imaging, inadequate decompression – this paper uses the term “pain generator” for the potential source of nociception, but you and I know that pain only occurs as an output of the brain within a biopsychosocial system; lots of other surgical issues including bleeding, fragments of tissue, “battered root syndrome” (!) where the nerve root is damaged during discectomy; and finally, there are a load of post-operative issues as well – such as haematoma, pseudoarthritis, fibrosis, irritation of the nerve roots, spinal instability, loss of disc height and the list goes on.

Shapiro suggests that some types of ongoing pain after surgery are misdiagnosed myofascial pain, stirring up or producing trigger points. He does add that central sensitisation in the dorsal horn could also play a part, expanding receptive fields in the spinal cord and amplifying “perception” (once again, think of this as amplifying nociceptive input reaching the brain). He also favours the notion of motor control problems following surgery, again compounding the problems that occur with movement after surgery and feeding back into the ongoing pain experienced by the individual.

Shapiro also goes on to suggest various ways the problems could be ameliorated, primarily through careful imaging and then possible surgical management.  The overall management, however, he argues should be pharmacological, “with the goal of increasing physical activity and community involvement”.  Interestingly, Shapiro says “FBSS patients are often pushed aside and told that their surgeons have little to offer them after their surgeries were unsuccessful. These patients are generally managed by community-based physicians, including primary care physicians, anesthesiologists, physiatrists, and neurologists.”  He goes on to say “Treatment of FBSS demands recognition that it is a chronic pain syndrome. One reason that FBSS is a difficult-to-treat syndrome and a public health problem is that the antecedent back pain did not respond to intervention and was often augmented with additional pain complaints caused by the surgery. The psychosocial burden for individuals is huge, especially if there is job loss or loss of function physically. Many of the immediate postoperative pharmacologic strategies complicate the situation further by altering the patient sensorium, mood, affect, and even libido. Opioid-induced hyperalgesia is probably under-recognized and under-reported.”

What does this mean to me?

It must be terribly distressing to be offered a treatment for low back pain and leg pain that is both invasive and expensive – only to find that it hasn’t helped one bit. And even more distressing to then be advised that “there is nothing more I can do, it’s a risk of having surgery”. Worse, then to be advised that the options for managing this pain are quite limited – and for many people, means repeated surgery, perhaps even to the point of having a spinal cord stimulator implanted (with all the known complications of this kind of intervention). Shapiro describes people being offered facet joint radiofrequency neurotomy, but even he acknowledges that “it does not offer a permanent fix to facet-mediated pain, which should raise concern with regard to overutilisation”.

What astonishes me, but probably shouldn’t, is that interdisciplinary pain management approaches continue to be seen as costly, yet there is ample research showing these programmes achieve clinical and cost-effective improvements in patient function.  I’ll let you draw your own conclusions from the following paragraph snipped from Shapiro’s paper:

The cost for this individually tailored 20-day outpatient program, including physical therapy, occupational therapy, and psychological support, is approximately $15,000 (Pain SolutionsNetwork, personal communication, 2013). This is similar to the cost for a single-level laminectomy not requiring a hospital stay and is substantially less costly than the direct costs for lumbar fusion when hospital, hardware, surgeon, and anesthesia costs are added up. [and I’d go even further to add that the 30% risk of a poor outcome is even more expensive…]

I think the health system has failed the people who undergo surgery for low back pain. With a failure rate quoted by Shapiro as approximately 30%, and an increase in epidural injections and facet joint injections of over 250% without any similar improvement in health status, something is going wrong. Very wrong.

Allied health professionals can and do provide cost-effective interdisciplinary pain management for people living with so-called “failed” back surgery syndrome. I think it’s time for allied health professionals to begin agitating, and perhaps even advertising direct to people who have pain – we can help. Our treatments don’t have the risks of invasive procedures. We are focused on helping you DO despite your pain. And what we do can hardly make your pain worse – unlike some of the very sad stories I’ve read.

 

 

Chan C, Peng P. (2011). Failed back surgery syndrome. Pain Medicine 12:577–606.

Shapiro, C.M. (2014). The failed back surgery syndrome: Pitfalls surrounding evaluation and treatment. Physical Medicine & Rehabilitation Clinics of North America, 25(2), 319-340.

Rhodin, A. (2014). A case of severe low back pain after surgery. Journal of Pain & Palliative Care Pharmacotherapy, 28(2), 167-168; discussion 168-169.

13 comments

  1. Thanks for posting a very timely and provocative article. As you would expect, I cannot go along with Shapiro’s speculation about “misdiagnosed trigger points”. They have never been shown to exist!

    However, there may be another important issue to consider. In my experience as a rheumatologist, there was a tendency for spinal surgeons to abandon their patients who come under systems of workers’ compensation when the outcomes of their surgical endeavours were less than ideal. Is this still happening?

    1. I think it happens whenever the outcome doesn’t fit with their expectations, irrespective of the funder! I think that happens to a certain extent with every healthcare provider, once the outcome doesn’t fit what expectations, the person receiving the treatment is pretty much left to their own devices. That is, of course, unless the treatment provider is utterly convinced that there is “just one more thing to try”. Then, unfortunately, it’s like “if the first attempt didn’t work let’s keep doing it until it does”. A lot like the old insanity definition – doing the same thing again and again and hoping for a different result.

      Shapiro’s points about trigger points notwithstanding, I do like his suggestions (which I didn’t include in my summary):
      “In summary, there are several generalizations that can be made regarding pitfalls to
      avoid in the treatment of FBSS:
      – First, interventional procedures should only be used to control flares of pain, re-
      turning patients to preinjection baselines; to allow them to partake in restorative
      physical therapy; or as diagnostic measures that may guide other treatments.
      – Second, the role of pharmacotherapy can be expected to change because of
      increased recognition of opioid-induced hyperalgesia and the regulatory climate
      surrounding opioids.
      – Third, although no specific physical therapy recommendations can be universal,
      it is clear that the complications of immobility and deactivation make restoration
      of function imperative.
      – Finally, medical education is going to have to be broadened so that physicians
      learn to focus on functional performance and avoid assigning importance to
      terms that are diagnostically ambiguous, such as degenerative disk disease, or
      assigning significance to MRI findings without confirming correlation to pain
      complaints, loss of motor function, or bowel and bladder instability.”

      What I hear from surgeons is that they “couldn’t say no to the patient” – like the patient knows best. Is this a good way to carry out surgery? Or any other invasive treatment? I also note the exponential increase in injection based procedures – 250%! And no measurable improvement in outcome. Doesn’t really speak well of the emphasis on “finding the source of the nociception”.

      1. Bronnie, the bigger question is about how clinicians respond to clinical uncertainty.

        Here is a quote from a relevant and excellent paper on the subject:

        “Our education is focused primarily on increasing our knowledge base, developing our skills in accessing the evidence, and refining our clinical reasoning, all in service of the false assumption that every clinical problem can be solved.”

        This paper should be made compulsory reading for all health professionals. But who is listening?

        Perhaps “living with clinical uncertainty” might appeal to you as subject worth exploring on HealthSkills?

        Reference: Guenter D, Fowler N, Lee L. Clinical uncertainty: helping our learners. Canadian Family Physician 2011; 57: 120-122.

      2. I love that quote! And I’ve been pondering this a great deal recently, particularly in light of comments that pain treatment should be the aim rather than pain management. At least part of the problem we have in chronic pain management is the idea that it “should” be possible to get rid of or successfully treat ALL pain. I don’t think the current state of research supports this in any modality or condition. For this reason alone I think we need to be honest, and realistic in our appraisals of treatment outcomes, and let people know that although we can’t get rid of all pain, we do have good ways to help people live well despite their pain. It’s not a popular concept, but I think it’s realistic and more humane than promising what can’t be currently delivered. I’d love to know what people living with pain think of this.

      3. Bronnie, it may sound trite but we do not attempt to treat or manage a “thing” called “pain”. As you rightly point out, it is the person in front of us who is asking for help. Unfortunately, the tendency to reify “pain” is ubiquitous in our society and as health professionals we are not exempted from falling into this trap.

      4. Yes! I do too, even though I don’t do anything to ameliorate pain intensity! BUT people (including people living with pain) also reify the experience – question is whether this is something that is inherently bad, or exactly what the effect is. I do think it’s critical to remember that we are two people meeting in a shared space for a specific purpose – to attempt to understand one another and reduce distress and disability. And if that’s kept firmly in mind, the tendency for all of us to think of pain as a “thing” that can be fiddled about with might be tempered with the recognition that we are dealing with an experience that is fluid and inherently human.

  2. I truly believe in this condition having had four back surgeries and am still replete with peripheral neuropathy, degenerative stenosis symptoms of buttock heaviness and lower back pain that impedes walking distance ability. All the gabapentin in the world doesn’t help. Certainly stress is a contributing factor to its aggravation.Still, my condition has helped me become much more empathic to helping those patients suffering with similar dilemmas. I lead a free support group where war stories unfold exponentially. Despite these conditions, treatment by opiates and, hopefully by medical marijuana, prove valuable despite the systems desire to curtail such dispensing. The support for one another is invaluable given 1 in 3 Americans suffer from chronic pain.  George Beilin, Ed.D

    Sent via the Samsung GALAXY S® 5, an AT&T 4G LTE smartphone

    1. Exactly! In the end people are what’s important – in Maori “He aha te mea nui o te ao? He tangata! He tangata! He tangata!” What is the most important thing in the world? It is people! It is people! It is people!

  3. I would say where I practice most people get abandoned by their surgeon when things don’t go well work comp or not..It is “the surgery didnt work maybe we can throw some injections at it or more surgery” if the patient understandably doesnt want more surgery then they are shown the door as that is all the surgeon offers. It is particularly bad in work comp as if the client says no to surgery then the system will say that they are going against medical advice then try to settle up and get them off their payroll.

    1. Yes, we see it here too! I’m not entirely sure whether this is a deliberate ploy, or whether it represents clinicians who truly cannot believe they have been unable to help and think there is nothing more to do. I guess it depends a lot on how widely the clinician reads around the topic of pain. If a surgeon wants to, he or she may not read about pain at all – but just read about spine anatomy and physiology. Learning about the complexities of pain doesn’t really get a look-in in many clinical specialties.

  4. I think here it is their “world view” I so often here from my clients that the doctor will say something to the effect of “Look at these pictures, nothing but surgery can fix that” or “that is the worst (fill in the blank) that I have ever seen. I think they believe they are helping the patient by giving them a sure answer so they dont go to surgery with doubt in their mind if they need it or not.

    I also know they think their is nothing more to be done…The knowledge about pain among ortho surgeons here is shockingly poor. And when I talk to one about pain he looks at me the same way he might look at a faith healer or something.

  5. I’ve heard similar things, though it’s hard to tell whether the surgeon actually says this, or it’s what the client/patient heard. Whatever the case the person believes that they ARE the worst case ever and it’s a challenge to reverse that belief.
    I once suggested I talk about CRPS with the orthopaedic surgeons – they almost fell about laughing, didn’t think it was something they’d encounter. Likewise fibromyalgia – they believe it doesn’t really exist (can’t see it on imaging, therefore doesn’t exist). But persistence and gentle exposure through authoritative research papers written in language they understand, and things will change. Eventually.

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