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Failed back surgery syndrome


Introduction

Although the term involves controversy, failed back surgery syndrome (FBSS) is defined as lumbar pain with or without radicular symptom that persists or appears after one or several surgical interventions. FBSS is not necessarily the consequence of a failed surgical procedure but rather a mismatch between the outcome and the patient’s and surgeon’s presurgical expectations. Specific reasons for pain, including infection, pseudomeningocele, and/or hematoma, should be ruled out before establishing FBSS as a diagnosis. The incidence of FBSS ranges between 10% and 40%. Moreover, low back pain lifetime prevalence is estimated to range between 60% and 85%, with an estimated global incidence of 9.4%. Therefore, low back pain represents a critical health problem and entails significant social, financial, and psychological consequences for the patients. Preoperative patient-related conditions such as anxiety, hypochondriasis, and cognitive impairment may negatively influence surgical outcomes. Similarly, poor patient selection and inadequate surgical planning are well known predisposing factors for the development of this syndrome. Insufficient decompression of the lateral recess or the neural foramen is the most common cause of failed surgical technique leading to FBSS, accounting for 25% to 29% of the cases. Postoperative issues may also contribute and include recurrent disc herniations (in up to 15% of the patients), epidural fibrosis (20%–36%), and postsurgical instability. Diagnosis of this condition must include a careful matching of the clinical presentation with the suspected anatomical anomaly, as well as a psychosocial assessment that includes behavioral elements such as anxiety disorder and secondary gain. Treating patients with chronic pain persisting after spine surgery is extremely challenging and requires multidisciplinary medical approaches. Currently, there are no high-level studies supporting specific management strategies for FBSS. However, after excluding clear indications for decompression or restoration of physiological spine balance, treatment of FBSS should begin with conservative management (including cognitive behavioral therapies), followed by minimally invasive procedures, and finally surgical interventions. Surgical treatment for FBSS is controversial and is sometimes associated with worsening of the clinical symptoms. Studies report that no more than 30% of the patients have a successful outcome after a second surgery and that the percentage of patients experiencing resolution of their symptoms diminishes with each subsequent surgical procedure. Therefore, surgical treatment for FBSS is reserved for patients with clear anatomical or pathological cause for their pain, typically after failure of nonsurgical treatment. We present a case of a 63-year-old male presenting with chronic pain and radicular symptoms after multiple spine surgeries and diagnosis concerning for FBSS.

Example case

  • Chief complaint: lower limb pain

  • History of present illness: This is a 63-year-old male with a history of multiple lumbar surgeries, including instrumented fusion and three revision laminectomies. The patient presented with persistent bilateral lower extremity pain, with the pain markedly worse in his left leg. His pain has been constant for many years with a recent worsening. His last surgery was 1 year prior and latest imaging showed solid fusion of his lumbar construct. Additionally, a lumbosacral magnetic resonance imaging (MRI) was performed, demonstrating findings compatible with arachnoiditis ( Fig. 21.1 ).

    Fig. 21.1, Preoperative images. (A) Computed tomography axial and sagittal views of the lumbosacral spine demonstrating prior solid fusion at L2-S1 levels. There is diffuse osteopenia as well as degenerative changes including irregularities involving the end plates and osteophytes. The patient is markedly hypolordotic at L3 to S1 levels and no compensatory changes are noted. (B) T2-sagittal lumbar magnetic resonance images demonstrating the previous fusion at L2 to S1 levels, degenerative changes including osteochondrosis and osteophytes from L2 to L5. There is decreased intervertebral space at L4-L5 and significant disc protrusion at L3-L4 and L5-S1. As mentioned above, loss of lumbar lordosis is evident. There is an image suggestive of lumbosacral arachnoiditis (empty theca sign).

  • Medications: oxycodone, fentanyl patch

  • Allergies: no known drug allergies

  • Past medical and surgical history: chronic pain, previous L2-sacrum fusion and decompression with three revisions and last surgery was complicated by cerebrospinal fluid leakage

  • Family history: none

  • Social history: smoker

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation diminished in his lower left limb with an L4, L5 distribution.

  • Richard Allen, MD, PhD

  • Jakub Sikora, MD

  • Orthopaedic Surgery

  • University of California at San Diego

  • San Diego, California, United States

  • Rafid Al-Mahfoudh, MBChB

  • Neurosurgery

  • Brighton and Sussex University Hospitals

  • Brighton, United Kingdom

  • Aron Lazary, MD, PhD

  • Orthopaedic Surgery

  • Buda Health Center

  • Semmelweis University

  • Budapest, Hungary

  • Allan D. Levi, MD, PhD

  • Meng Huang, MD

  • Neurosurgery

  • University of Miami

  • Miami, Florida, United States

Preoperative
Additional tests requested

  • Full-length standing 36-inch scoliosis x-rays

  • CT T-L spine myelogram

  • DEXA

  • SPECT CT

  • NCS/EMG

  • L-spine standing x-rays

  • Pain management evaluation

  • Full spines standing x-rays

  • L-spine flexion-extension x-rays

  • L-spine upright AP/lateral/flexion-extension x-rays

  • DEXA

Surgical approach selected

  • Stage 1: posterior removal of instrumentation, L4-S1 revision decompression with laminectomy, L2-4 exploration of fusion

  • Stage 2: L5-S1 ALIF

  • Stage 3: L2-pelvis fusion including pelvic bolts

T9-10 thoracic laminectomy and insertion of spinal cord stimulator lead for trial

  • Stage 1: removal of S1 implant

  • Stage 2: L5-S1 ALIF

Revision L5-S1 fusion with lateral MIS L5-S1 ALIF (XALIF), prone L5-S1 MIS revision fusion
Goal of surgery Spinal canal decompression, solid fusion Pain management Stabilization, lordosis correction, L5-S1 fusion Restore intervertebral height, indirect decompression of L5-S1 foramina, achieve solid arthrodesis at L5-S1 with improvement of lordosis to improve spinal-pelvic parameters
Perioperative
Positioning

  • Stage 1: prone on Jackson table

  • Stage 2: supine

  • Stage 3: prone on Jackson table

Prone on Montreal mattress

  • Stage 1: prone

  • Stage 2: supine

  • Stage 1: right lateral decubitus on radiolucent table

  • Stage 2: prone on Jackson table

Surgical equipment

  • Fluoroscopy

  • Osteotomes

  • Vertebroplasty set

  • Fluoroscopy

  • Surgical microscope

Fluoroscopy

  • IOM (MEP, SSEP)

  • Instrument removal set

  • Anterior and posterior instrumentation

  • Pulse oximetry for left leg

  • Fluoroscopy

  • Surgical navigation

  • Isocentric C-arm for cone beam CT

  • Cobalt drill

Medications Tranexamic acid None None Gabapentin, Celebrex, steroids, bupivacaine liposome injection suspension with bupivacaine 1:1, Toradol
Anatomical considerations Thecal sac, middle sacral arteries, sympathetic plexus Thecal sac, lamina

  • Stage 1: thecal sac

  • Stage 2: peritoneum, iliac artery and veins

Common iliac vessels and branches, peritoneum, ureter, sympathetic plexus
Complications feared with approach chosen Pseudoarthrosis, vascular complications Epidural fibrosis

  • Stage 1: dural tear

  • Stage 2: peritoneal and iliac vessel injury, hypogastric plexus injury

CSF leak
Intraoperative
Anesthesia General General General General
Exposure

  • Stage 1: L2-S1

  • Stage 2: L5-S1

  • Stage 3: L2-sacrum

T9-10

  • Stage 1: L5-S1

  • Stage 2: L5-S1

  • Stage 1: L5-S1 anteriorly

  • Stage 2: L5-S1

Levels decompressed

  • Stage 1: L4-S1

  • Stage 2: L5-S1

  • Stage 3: None

T9-10

  • Stage 1: None

  • Stage 2: L5-S1

L5-S1
Levels fused

  • Stage 1: L2-S1

  • Stage 2: L5-S1

  • Stage 3: L2-pelvis

None

  • Stage 1: None

  • Stage 2: L5-S1

L5-S1
Surgical narrative

  • Stage 1: position prone, incision over previous midline scar at L2-sacrum, expose previous instrumentation and fusion site, remove all set screws and rods, evaluate L2-4 fusion site and screw stability, leave screws in if no concern of pseudoarthroses, remove screws and upsize and/or redirect if concern of loosening, assess decompression and perform revision laminectomy and decompression L4-S1, place S2 anterior iliac screws, preliminary closure

  • Stage 2 (same day): position supine, vascular surgery performs anterior retroperitoneal approach, L5-S1 annulotomy, release disc space with Cobb retractors, remove disc, expand space further with trials and serially dilate space carefully, decompress entire disc material and take cartilage end plates off, ensure nice punctate bleeding in bone bed before rasping, impact 18/20 degree PEEK cage with BMP-2 and cellular bone matrix, place two stabilizing screws through interbody into L5 and S1, vascular surgery closure

  • Stage 3 (same day): position prone, contour two rods appropriately, place rods with set screws, copiously irrigate, decorticate, place autograft and BMP-2/demineralized bone matrix/cancellous chips, take final AP and lateral image, verify placement of instrumentation, powder vancomycin into wound, layered closure with drain and Marcaine in subcutaneous tissue

Position prone, paramedian needle to localize operative level, midline incision, bilateral muscle dissection, placement of McCulloch retractor, check x-ray to confirm T9-10 level, microscope brought in, laminectomy with high-speed drill, remainder of lamina removed with flavectomy once bone thinned, paddle tunneller and placement of spinal cord stimulator, tunnel out separate incision and connected to further lead that is tunneled percutaneously to the skin, closure in layers

  • Stage 1: position prone, open caudal 5–6 cm of the posterior scar, dissection down to L5-S1 segment, cut rods under L5 screws and remove S1 screws, layered closure with drain

  • Stage 2: position supine, 6 cm horizontal skin incision half-way between navel and pubic symphysis, explore rectus sheet and cut linea alba, mobilize rectus muscle fibers to left from medial to lateral, explore posterior rectus sheet and use arcuate line to approach retroperitoneal fat, peritoneum bluntly mobilized and retracted cranially, identify left iliac artery by palpation, identify medially the promontorium and bluntly dissect retroperitoneal tissue in front of L5-S1 disc, clean disc surface by blunt dissection with bipolar cautery, cut anterior anulus fibrosus and disc space, place a large hyperlordotic 20–30 degree ALIF cage based on preoperative x-ray filled with synthetic bone substitute or allograft, fix cage with screws or plates, standard closure without drain

Stage 1 (lateral XALIF): right lateral decubitus with left side up on radiolucent table with bed rail mounted retractor holders placed rostral on ipsilateral side and caudal on contralateral side, spine needles and fluoroscopy to localize and guide Wiltse approach to S1 screw heads, inject 5 mL of bupivacaine mixture into tracts prior to opening, incision and monopolar cautery to identify S1 tulip heads, remove set screw, pack off incisions, check cross table AP and mark midline with proper Ferguson angle, true lateral imaging to identify anterior/posterior boundaries of disc space and lordotic angle, extend line anteriorly to midline and split difference with AP mark and ASIS, approach surgeon performs retroperitoneal opening and access to disc space, set retractor blades, confirm disc level and medial-lateral positioning with fluoroscopy, ALIF with sequential distraction/dilation of disc space, achieve 20 degree hyperlordotic implant with proper interference fit, keep trial in place for 5 minutes to ensure no IOM changes from baseline, place implant with extrasmall BMP and cellular allograft, place anterior plate/screws with appropriate size to avoid collision with posterior transpedicular instrumentation, close anterior incision with closure of abdominal wall fascia, staple posterior incision closed. Stage 2 (revision posterior instrumentation): transfer patient prone on Jackson table, right PSIS pin placement with frame, cone beam CT for navigation, reopen incision with navigation guidance to remove L5 set screws, cobalt drill to cut rods proximal to L5 screw head, remove rods and L5-S1 screws, replace with 1 mm larger screws under navigation, retap at S1 with under navigation with powered undersized tap to breach anterior cortical wall to facilitate bicortical fixation, replace roads and screws, final cone beam CT to evaluate hardware, inject remainder of bupivacaine solution into paraspinal muscles, no drain
Complication avoidance Multistaged approach, examine fusion construct, upsize screws if needed, vascular surgery to help with approach, ensure nice punctate bleeding in bone bed before rasping, BMP to help fusion Spinal cord stimulator trial Two stage approach, remove implant posteriorly to allow more lordosis anteriorly, anatomical retroperitoneal approach to L5-S1 disc space, dissect with bipolar cautery near disc space, place hyperlordotic ALIF cage Identify S1 tulips first, retroperitoneal approach, restore lordosis with hyper lordotic implant, keep trial in for 5 minutes to ensure no IOM changes, surgical navigation, bicortical S1 pedicle screws, postinstrumentation cone beam CT
Postoperative
Admission Floor Floor Floor Floor/step down unit
Postoperative complications feared Vascular injury, ileus, FI complications, infections, dural tear Malposition of stimulator, epidural hematoma

  • Stage 1: dural tear, infection

  • Stage 2: peritoneal and iliac vessel injury, hypogastric plexus injury

Ileus, L5 nerve root traction injury, ischemic leg, sympathetic plexus injury
Anticipated length of stay 3 days 2–3 days 3 days 2–4 days
Follow-up testing L-spine x-rays 1 month, 3 months, 6 months, 1 year, 2 years after surgery Trial stimulation L-spine x-ray after drain removal Upright AP/lateral lumbar x-rays
Bracing TLSO for 12 weeks None None Soft lumbo-sacral orthotic
Follow-up visits 2 weeks, 1 month, 3 months, 6 months, 1 year, 2 years after surgery 1–2 days for implantation of generator if trial stimulation successful 3 months, 6 months, 12 months after surgery 2 weeks after surgery with nurse visit, 6 and 12 weeks with x-rays, 9 months with lumbar CT and 36 in AP and lateral upright x-rays
ALIF , Anterior lumbar interbody fusion; AP , anteroposterior; BMP , bone morphogenic protein; CSF , cerebrospinal fluid; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; EMG , electromyography; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MIS , minimally invasive surgery; NCS , nerve conduction study; PEEK , polyetheretherketone; PSIS , posterior superior iliac spine; SPECT , single-photon emission computerized tomography; SSEP , somatosensory evoked potentials; TLSO, thoracic lumbar sacral orthosis.

Differential diagnosis

  • ▪

    Recurrent disc herniation

  • ▪

    Hardware malfunction/malposition

  • ▪

    Nerve root compression/foraminal stenosis

  • ▪

    Epidural abscess/hematoma

  • ▪

    Malingering/psychological disorders

  • ▪

    Failed back syndrome

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