Dr. Ebraheim’s educational animated video describes conditions that may cause back surgery to fail?
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What is the definition of failed back surgery syndrome?
The definition is persistent, new appearing, recurrent low back pain or lower extremity pain following one or more spine surgeries that was thought to be likely to relieve the pain of the lower back. The outcome of spine surgery does not meet the expectations of the patient and the surgeon.
Common causes of failed lower back surgery are:
• Operation on the wrong patient
• Incorrect diagnosis
• Incorrect procedure
• Poor technique
• The problem came back or may be progressive
• We failed to match the patient’s goals with our ability to achieve these goals, so we get an unexpected outcome, and the patient is dissatisfied.
Back surgery is better for leg pain than for low back pain. In absolute indications for surgery are cauda equina syndrome that causes bladder and bowel disturbance or progressive neurological deficit. The usual indication for surgery is that the patient’s symptoms are not resolved with nonoperative treatment. 80% will rely on the history, 15% will rely on the physical exam and 5% will rely on the studies for diagnosis. Patient with failed back surgery syndrome means that there is no improvement. Causes that can lead to failed back surgery syndrome:
• Poor patient selection (the most common cause of failed back surgery syndrome
- The patient has problems that we did not address before surgery
- The patient may have intrinsic psychological disturbance, they have elevation of hysteria, hypochondriasis, depression and anxiety, and abnormal pain behavior.
To predict the outcome, the patient will need evaluation incorporating a comprehensive variety of medical and psychological risk factors, which can be predictive of spine surgery outcome in about 82% of the patients.
• We made the wrong diagnosis
- Either the diagnosis is incorrect or incomplete
- May be relied on the MRI and the x-rays that incorrectly shows degenerative changes which is age related and asymptomatic in a lot of patients
- The physician must correlate the patient’s symptoms with physical examination and imaging. When they are not aligned, the chance of failure is increased.
- Failure to diagnose a painful transitional segment above or below an area to be fused may cause the pain to continue after surgery.
- Failure to diagnose a far lateral herniated disc may result in failure to relieve the leg pain.
- Failure to address foraminal or lateral stenosis in a patient with central stenosis may result in continued radicular pain
• The doctors chose the wrong procedure
- Operating on the wrong level is the most common error and intraoperative radiographic localization in all cases is important.
- The doctor may have gone posteriorly instead of anteriorly and vice versa, or the doctor did decompression of one site when the patient has multiple painful sites.
- Doctors are missing other pathology that they did not address.
• Poor Technique
- You selected the patient properly, diagnosed the case very well, you chose the proper surgical procedure, but a poor technique was done.
- Incomplete decompression was done, the doctor left the residual deformity, or the doctor caused iatrogenic instability or battered root syndrome.
• Progressive Disease or Recurrent Pathology
- Recurrent disc herniation, recurrent spinal stenosis, or transition syndrome.
- Recurrent disc herniation occurs in about 5-15% of the time. Half of them occur in a new level or on the other side
Stability of the fused segment will increase the load on the adjacent segment and accelerate disc degeneration (transition syndrome). This syndrome occurs in lumbar spine surgery patients up to 30% within 10 years. Patients will have x-ray evidence of segment deterioration. A similar process occurs with time that is at the SI joint and occurs after lumbar fusion with the degeneration extending to the SI joint. Incidence is about 40%.
• Failure to Achieve the Goals of Surgery
- The decompression was inadequate or incomplete and the correction of the deformity was inadequate or incomplete, or the patient may have a nonunion.
- Our procedure failed to achieve these goals so there is an unexpected, adverse or unfavorable outcome and the patients usually do not like that.
• There may be a new source of pain that may not be related to the initial surgery
- Consider the potential source of symptoms, then this can help in directing the appropriate diagnostic study and the appropriate treatment. Look for occult chronic infection. Look for occult nonunion, persistent stenosis, or alignment that is not corrected. Look for other anatomic sites that cause similar problems such as the hip and SI joint. Assess the vascular disease, the hip and assess the patient for peripheral neuropathy. Assess findings of pain behavior like Waddell Signs.

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