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Medical and Surgical Treatments The best treatment for each patient must be based on an accurate diagnosis. Although it is appealing to have the latest procedure, the newest medication, the smallest micro-surgery or arthroscopic surgery, best treatment must be appropriate for each individual patient’s condition. Treatment must also be based on scientific evidence, not marketing on television or in news magazines. At SpineCare, we pride ourselves on making correct and complete diagnoses, and then offering our patients the most effective treatment for their unique problems. We cannot jump at the latest fad, things that have not been proven to work. Our patients and our reputation mean too much for that. Spine surgery must be taken seriously. It is imperative to select the right procedure for the right patient at the right time. Many of the terms discussed here are also defined in the SpineCare glossary and illustrated in the section on anatomy. Failed Spine Surgery Most patients who undergo spine surgery improve. However, some patients do not get better, and a few patients get worse. Because we are a specialized spine center, many patients are referred to SpineCare because their previous surgery did not relieve their pain. We have become very experienced in and knowledgeable about so-called “failed spine surgery,” and we are gratified that we have been able to help many patients who have been told by other doctors that nothing can be done. There are many reasons for failed back surgery. Based on research done at SpineCare and research done by others, we know the most common causes are narrowing of the nerve canals (neural foramen) and pain from the disc itself (discogenic pain), although there may be more than one cause for the pain. There are many reasons that these failures occur. Some are technical failures—the surgeon was not able to fix the problem. Some are judgment errors—the surgery was done to fix a problem the doctor saw on X-rays or scans, but these were not the actual cause of the pain. Some failures are due to an entirely new problem that causes the same symptoms, and the original problem was fixed. It is our job to find out the exact cause of the pain in each patient. In order to find the exact cause of pain, we use advanced testing methods, the highest quality scans and very specialized injections. Then, once we have discovered the cause of the pain, we can offer the patient the best treatment for the specific problem. Some patients need further surgery, others should be treated with medications or spinal cord stimulation, and some need a combination of treatments. Once again, the best treatment must be designed for each patient. Many of our patients have been told their problem is scar tissue. But every surgical patient has scar tissue, even those who get better. Therefore, we do not believe scar tissue is a major cause of failed surgery. Sometimes scar tissue is blamed when no other cause can be found. Because we know what we are looking for, we look harder, and can find the source of the pain in almost all of our patients. The following is a summary of our research on failed back surgery that our group presented in 1998 at a research meeting of the North American Spine Society. The Causes of Failed Back Surgery We reviewed the charts of 183 consecutive patients who were seen because of continued pain despite lumbar spine surgery done elsewhere. There has been no published research on this subject since the introduction of MRI, CT scans diagnostic, selective nerve root injections or discography. The diagnostic evaluation was individualized according to the needs of each patient. We were able to establish a “prominent diagnosis” in 95% of the patients. There were nine patients with more than one predominant diagnosis. The diagnoses were: foramenal stenosis 29%, painful disc(s) 17%, fusion not solid 15%, nerve damage 9%, recurrent disc herniation 6%, instability 5%, painful disc plus foramenal stenosis 4%, painful disc at the level of fusion 3%, psychological 3%, and others. We concluded that current advances in X-rays and diagnostic injections have improved our ability to find the cause of low back pain in patients with failed surgery. Residual foramenal stenosis remains the leading cause of FBSS but painful discs are very common. Recurrent disc herniation is not as common as it was years ago, and there is a better recognition of nerve damage as a cause of pain.

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