Failed Back Surgery Syndrome Presents Limited Treatment Options, As Revision Surgery May Make Matters Worse

For many unfortunate people who fall into the category of 'failed back surgery syndrome' or FBSS viable options for management is  a burning issue. The reasons for back surgery being unsuccessful - be it spinal fusion, disc replacement, laminectomy or discectomy - are multifarious and range from the surgeon operating on the wrong level, operating on the wrong structure, poor surgical technique leaving behind too many adhesions and removal of disc material creating post-operative instability. 

Look before you leap into back surgery to avoid the calamity of failed back surgery syndrome.

Sarah Key's small e-book Be Careful About Back Surgery will give you a lot of information on the indications for surgery with the different spinal conditions ~ with specific signs and symptoms you yourself can identify. The book discusses the pitfalls with spinal surgery and each surgical procedure and the common adverse outcomes.

1. Post-operative adhesions play a big role in failed back surgery syndrome

All surgical techniques on the spine - be it removal of part, or all, of a disc (discectomy or laminectomy), inserting hardware (artificial disc replacement) or using metal screws to stabilise a loose vertebra (spinal fusion) - involve extensive cutting and cauterising of the spinal soft tissues and drilling and shaving of bone. All spinal procedures cause massive bleeding and oozing of interstitial fluid into the tissues that must be dealt with at the time. if it is not dealt with , over time this exudate organises into hard stringy space-occupying junk tissue - known as post-operative adhesions. Adhesions are invasive, like weeds and undergrowth invading a pristine forest, and they can clog up the delicate spinal machinery.  post-operative adhesions also have a habit of shrinking and cobbling over time, which can trap and choke the spinal nerve roots as they make their way out of the spine. The nerves are more likely to get glued or embedded into adhesions if spinal movement stays restricted after surgery - and this is where early mobilisation is of paramount importance.  

2. Excessive bone growth after surgery may also contribute to FAILED BACK SURGERY SYNDROME

Bone is made of cancellous of honeycomb bone on the inside and a hard smooth layer of cortical bone on the outside. Drilling and shaving off the cortical bone subsequently causes the body's repair processes to kick in, in a sense to create another sealing-over layer of outer bone. Where possible, surgeons cover areas of denuded cortical bone with special inert surgical wax which inhibits bone proliferation. but this is harder to do in all the  convoluted interstices of the spine which may be too small or inaccessible to get at and Some surgeons are more careful and painstaking than others.
Although excess bone-growth is not irritating per se (bone is quite inert) it  clutters up the works and makes it more difficult for spinal movement to work away and disperse the softer-tissued adhesions. In some cases, a bony stricture or collar may develop at the operative spinal level, which dams up the blood supply up and down the spine and leads to symptoms of vertebral stenosis.

3. Reduced intradiscal pressure after micro-discectomy can also lead to failed back surgery syndrome 

The intervertebral disc is an ingenious structure. It works like water-filled pressure pillow between each vertebrae with a high intra-discal pressure. this internal pressure thrusts the vertebrae apart, countering the compressive effects of gravity, while at the same time absorbing impact and errant glitches of movement. Importantly, that same high internal disc pressure also stretches and tautens the tensile outer wall of the disc,  also contributing to the segment's stability in the spinal chain.  

Intra-discal pressure is reduced by approximately 40% after discectomy.  THis is caused by the puncturing of the disc wall by the surgeon's scalpel and then scooping out of nuclear material from the centre of the disc that the surgeon believes has lost cohesion and is causing the disc to bulge. (You may like to read about this likelihood in The Myth of The Slipped Disc). If the post-operative management is vigorous and sufficiently pro-active - specifically encouraging bending - the deep spinal muscles will compensate for this weak de-pressurised link. but if the spine is allowed to get weak (along with the trunk/abdominal muscles) chance unguarded movements, combined with normal wear and tear will see this vertebra gradually start to work loose.  Gradually the segment will become unstable