• 'Failed back surgery syndrome': application& relevant issues.

    21 September at 15:59 from atlas

    Date: 26th January 2012

    "Failed Back Surgery Syndrome" - facts and application issues

    Failed back syndrome (FBS),also referred to as "failed back surgery syndrome" (FBSS),is a term which has a limited legitimate status as a true syndrome for a variety of reasons.Its application is also of limited helpfulness and is somewhat arbitrarily applied (rarely to the surgeon's own cases!), unverifiable and in many cases a self-serving label for non-clinical purposes.

    Spinal surgery, like most other forms of surgery has a defined success , and failure rates.The difficulty in surgery is defining exactly what constitutes "success" and "failure".Does a case where a post-operative MR scan shows uncomplicated lumbar discectomy and nerve root decompression ,but the patient reporting continuing and unabating sciatica ,warrant the application of the emotive term "failed back surgery syndrome"? It is known, and should be part of the pre-operative decision making, and consent process, that lumbar discectomy for sciatica has a approximate 90% chance of resulting in the patient reporting relief of severe sciatica (and much less chance of resolving back pain).Thus after a technically" perfect" discectomy (nerve root decompressed without complication) the statistics are that approximately 10% of patients will report continuing severe sciatica. The explanation for such cases is not always clear and includes presumed intrinsic intra-neural injury,true neuropathy,poorly understood induced pain responses and secondary gain factors ( including financial compensation will be minimised, or lost, if patient reports relief of pain).Is it appropriate to use the term FBSS in such cases?The surgery did not fail to decompress the nerve root but it is known that in around 10% of cases the patient ,for whatever reason ,reports no improvement in the sciatica.There is no technical "failure" and it only works in some 90% of cases-so is the emotive term FBSS appropriate?Should similar terms be applied in cases where mastectomy and colectomy is not curative-"failed mastectomy or colectomy surgery".Why not? We know that even after compete & technically uncomplicated removal of the cancer there will be a defined mortality-is this a "failure"? Why is such emotive terminology applied in spinal surgery,often only by colleagues ,or lawyers?

    FBSS as a clinical diagnosis is often not worthy of its use. In most cases its use is arbitrary by colleagues and litigants.There is no often verifiable technical "failure",there is no verification , no explanation for ongoing symptoms (e.g. nerve root damage, infection,persisting compression etc) and the causes proposed are often inconsistent . The inherent implication is one of" failure" by the surgeon.Ofcourse, there are cases where an operation is doomed to fail and I refer by way of example, to cases of poor case selection by the surgeon in some fusion cases (e.g. multi-level anterior &posterior degeneration,no spondylolisthesis,no radiculopathy,narcotic dependency, secondary gain factors, smoking & obesity).Such cases have a very limited chance of success, and obviously a high chance of non-success.In these cases the term "failure" may be appropriate as the pathology causing the back pain persists and the operation performed was a poor choice and technically unsuccessful-the adjacent degeneration has not been corrected.If the operation was never clinically indicated then FBSS is appropriate in many authors view.Also if the surgery did not achieve its technical endpoint ,e.g. decompression of stenosis, then the term FBSS may be appropriate.

    Oaklander and North(2001, FBSS in Bonica's Management of Pain) define FBSS as a chronic pain patient after one or more spine surgical procedure.They noted that these patients made increasing demands on the surgeon for pain relief, became angry and litigious,were unlikely to return to gainful employment , often sought further surgery and with times the financial incentives to remain disabled exceeded the incentive to recover.

    Emeritus Professor Don Long(Neurosurg Clin N Am.1991 Oct:2(4) 899-919) noted 20 years ago, that the causes of back pain to be largely unknowm, correlation with diagnostic studies to be uncertain and the curret (1991) disability-litigation system to be" greatly adding to the problem".He noted that patients were rewarded for nonfunction and that some doctors became patient advocates, and others for insurers.

    Lina Talbot (BMJ Vol 327,985-7)estimated that around 2000 cases of FBSS are diagnosed in the U.K a year and that surgery for prolapsed disc fails to reieve pain in 5-10% of cases.Jos Verbeek in a BMJ commentary commented that the FBSS "label' was unhelpful, not diagnostic of an actual explanation and may even play a part in the patient's deterioration.He felt that in 50% of cases the cause was not clear.excluding recurrece of disc herniation.He felt that instability,and epidural fibrosis not to be linked to either pain or disability and were controversial.

    Van Gothem et al (Neuroradiology.1996.38 Suppl 1:S90-6)examined 34 consecutive cases with excellent clinical outcome after lumbar discectomy by gadoliniuim enhanced MRI 6 weeks and 6 months after surgery.Contrast enhancement was seen in all patients at the surgical site at 6 weeks and 6 months.Enhancing nerve roots were seen in 20% of cases at 6 weeksand half of these had recurrent disc herniation (yet were asymptomatic).These authors cautioned that post-operative MRI studies must be interpreted with 'great care" since "the features described in the FBSS are also found to some extent, in asymptomatic postoperative patients".Herno et al ( various Spine 1999) also noted that post-operative imaging must be carefully correlated clinically.Post operative granulation and fibrosis is expected after spinal surgery and maust be carefully correlated by an experienced spinal surgeon.It is most often seen around the L5 and S1 roots(Hinton, Jl,L 1995,Fischgrund,JS 2000 and Benoit,M 1980).

    Professor Porter ,RW (Journal of Royal college of Surgeons Edinburgh.1997;42;376-380)advises that the decision to operate on the spine requires" mature judgement" as it is technically difficult, demands a high level of surgical skill and is only learnt after a lengthy apprenticeship.He warns that surgery should" only be offered in the patient's best interest". Porter notes that one of the most common causes for patient dissatisfaction is failure to receive sufficient information about surgery and its risks.He relates that when performing a discectomy there is a 90% chance of relief of leg pain,decompressing a stenosis there is 60% chance of relieving the claudication and perhaps 60% chance of also relieving chronic back pain by fusion.Porter concludes that most patients do well and that patients who have been carefully selected prior to surgery,undergo competent surgery and good postoperative care are significantly helped by their surgery.

    I BELIEVE that spinal surgery is a complex area of surgery and the use of the term FBSS must be carefully considered. It often does not help in patients' treatment , and it also has emotive suggestions of possible wrong doing ("failure")by the surgeon- USUALLY, BUT NOT ALWAYS unjustified as discussed above.The overall recommendations to avoid the "FBSS label", usually by colleagues and litigants are clear: make the correct surgical diagnosis before surgery ; discuss options, surgical indications,expectations, appropriateness of each option ,and risks in detail BEFORE surgery ; be well trained and experienced ; operate ONLY for the patient's best interests ;perform meticulous surgery & follow up your patient carfefully. Despite doing all of this, a spinal surgeon may have one of his cases POSSIBLY inappropriately labelled as "FBSS" -this is most distressing to a caring and meticulous spinal surgeon, and usually does little to actually assist in the patient's management.Rarely do surgeons label their own cases as "FBSS"-this is curious ,as it is these surgeons who prescribe multiple S8 narcotics, total disability certificates and repeatedly want insurers to pay them to re-operate, yet the term "FBSS" NEVER appears on their own certificates. However, it is usually these surgeons who will OFTEN diagnose colleagues' cases as such-despite none of these concerning indiciae being present-a serious inconsistency!

    The use of the term FBSS by a surgeon, or lawyer, MANDATES carefully applied balanced objective imparial and evidence-based consideration; ability to justify objectively and scientifically in detail its application (not simply as a paid advocate), and ofcourse the "labeller " MUST have extensive and senior training and qualifications with decades of actual spinal surgery. .......otherwise, there may be experts armed with these skills- extensive training ,academic knowledge and multiple appropriate qualifications available to address the labelling appropriately,objectively, impartially and academically......