Will My Lower Back Surgery Fail? Criteria for Low Back Surgery
Are you contemplating lower back surgery?
What criteria clearly indicates you need back surgery?
When should you do conservative care instead of surgery?
Failed Back Surgery Syndrome ( FBSS ) is recurring or persistent pain in the low back or low back pain with pain down the leg after spinal surgery. It’s incredible that 10-50% of people have Failed Back Surgery Syndrome (FBSS). 
The failure rate for microdiscectomy surgery is 19-25% while lumbar fusion has a failure rate of 30-46%.
The results two years after laminectomy surgery for back pain and for people treated conservatively are very similar. Laminectomy surgery is when a part of your vertebrae is taken out like cutting off the back of your car. The idea is that if you cut out the back part of your vertebrae your nerve can’t be pinched between your disc and your vertebrae.
Why would you get Laminectomy surgery than? There is one advantage. Speed. Those that got the laminectomy surgery got better faster. For most people it’s better to get conservative care as it doesn’t change your spine permanently.
However if it means that you will lose your job or have no income for a year or two it might be worth taking the risks for surgery. It’s partially the individual’s choice dependent on your particular circumstances.
Also your own perception of your pain will play a big part. If you feel your pain is extremely painful you will more likely to want surgery. However most surgeons will tell you that you should do at least 6-12 months of conservative care before doing surgery. That is the ethical thing to do. In fact if you don’t match the criteria for surgery below and your surgeon is recommending surgery without conservative care for at least 6 months a red flag should appear in your head.
Criteria For Surgery
- Progressive wasting or weakening of muscles.
- Cauda Equina Syndrome: Loss of bowel or bladder function.
- Surgery is more successful if the disc herniation is 8mm or larger for microdiscectomy. In other words the success rate for microdiscectomy is very low for disc herniations that don’t bulge out past 8mm.
- 6-12 months of conservative therapy has failed to make progress. If you are progressing with conservative therapy you should keep going with it. Conservative care are things like chiropractic care, rehabilitation, stabilization exercises, acupuncture, traction, McKenzie exercises and physical therapy.
So Why Do People Have Failed Back Surgery Syndrome?
- When you have an open Workers compensation regarding your lower back.
- When there is an ongoing court case regarding your lower back.
- Prior Surgery- After your first disc surgery 12% of you will get spinal instability. 
- Depression, anxiety and hypochondriasis and somatization.
- Abnormal X-rays, MRI or CAT scans that can’t be linked to your pain.
- Operating on the wrong disc.
- Surgeon didn’t take enough pressure off your disc.
- Surgeon trying to take too much pressure off the disc making the spine unstable.
- Degenerative Disc Disease- Smaller disc height.
- Unidentified pathology: eg. disc parts in the foramen (opening or tunnel for the nerve) or nerve root compression by the vertebral joints called facets as surgeons usually don’t operate on the facets.
- Battered Root Syndrome: You have sciatica that didn’t completely go away or nerve problems like sciatica or weakness that get worse 3-6 months after surgery.
- Surgeon fractures your vertebrae: Usually the pars interarticularis.
- Prolonged retraction: When a surgeon operates to get to the disc there is a thick layer of muscle that covers the vertebrae. Your muscle has to be cut, and pulled out of the way and held there with a clamp. That is called retraction.
- Myofascial pain: Myofasical is referring to muscles. It is common for your muscles to hurt after surgery.
- Surgical Scars: Surgery can damage tissues which cause pain called nociceptive pain and when nerves are damaged cause neuropathic pain. For example scar tissue that is hypersensitive is nociceptive pain. When nerves stick to other tissue and cause pain this is called neuropathic pain as the pain comes from the nerve itself. Neuopathic pain is like sciatica that comes months after surgery due to scar tissue attaching to the sciatic nerve.
Complications After Surgery
- Infection or hematoma which is a blood clot in tissue.
- Non-fusion: The surgeon fused the joint but the fusion was unsuccessful leading to a pseudoathritis: Arthritis between two bones that failed to fuse.
- Pseudomenigocele: Your outer covering of your spinal cord fails to heal properly. You can get wound swelling, headaches or radicular pain or cauda equina. Headaches get intense when going from a lying down position to standing.
- Arachnoiditis: Spinal or thigh/leg pain: This is inflammation of the one of the outer covering of the spinal cord.
- Changes in spinal Stability: Your vertebrae and joints take more pressure after discectomy. [4-6]
- Epidural fibrosis: Surgery causes scar tissue to form. Your nerve gets stuck with scar tissue to adjacent tissue causing pain. This can also interfere with fluid circulation.
Failed Back Surgery Syndrome FBBS is very common. I treat dozens of people with FBSS here in downtown Toronto. Sometimes the surgery fails right from the beginning, while others feel worse after 6 months. Some are better and some are worse compared to their pain prior to surgery. The key is to do conservative therapy for at least 6-12 months before even considering surgery.
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1. Chan C, Peng P. Failed back surgery syndrome. Pain Med 2011; 12: 577–606.
2. Shapiro CM, Failed Back Surgery Syndrome: Pitfalls Surrounding Evaluation and Treatment, Physical Medicine & Rehabilitation Clinics of North America 2014; 24: 319-340.
3. Fokter SK, Yerby SA. Patient based outcomes for the operative treatment of degenerative lumbar spinal stenosis. Eur Spine J 2006; 15: 1661–9.
4. Kumar MN, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent level degneneration following lumbar spine fusion. Eur Spine J 2001; 10: 314–9.
5. Onesti ST. Failed back syndrome. Neurologist 2004; 10: 259–64.
6. Ivanov AA, Kiapour MS, Ebraheim NA, et al. Lumbar fusion leads to increases in angular motion and stress across sacroiliac joint. Spine 2009; 34(5): E162–9.
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