www.failedback.info
Contact Address: [link to address]
FAILED BACK SURGERY SYNDROME
Are you contemplating spinal surgery?
Have you already had a LAMINECTOMY and are still
hurting?
Have you had two or more laminectomies and now you
have been proposed a SPINAL FUSION?
Before going ahead, learn about the odds of ending up with
the diagnosis of FAILED BACK SURGERY
SYNDROME (FBSS) [link to failed back surgery
syndrome paper]
Although now a days, more and more patients are being labeled with this
DIAGNOSIS, it is not a disease, it is not contagious and it is not fatal;
however it usually is assigned to patients who after sustaining one or more
spinal operations and a number of interventions in the spine patients end up
with worse PAIN and DISABILITY than what they had when they first
sought medical care.
WHAT CAUSES FBSS? [link to causes]
YOU HAVE BEEN TOLD THAT YOUR BACK IS
UNSTABLE [link to unstable back]
ARE YOU LOOKING FOR ANSWERS [link to if you
find yourself in a quandary]
[link from first page] Contact address:
J. Antonio Aldrete, MD, MS
1 Perimeter Park South, Suite 100 North Tower
Birmingham, AL 35243
Tel: (205) 968-0068
Fax: (205) 968-8100
[link from first page] WHAT CAUSES FBSS?
This is the real question that every patient should analyze
before having spinal surgery. It can be simplified into the following well
accepted possibilities
a) INCORRECT DIAGNOSIS
b) UNNECESSARY SURGERY
c) IMPROPERLY PERFORMED SURGERY
d) PRE-EXISTENT CONDITIONS (usually congenital)
e) INADEQUATE IMAGING STUDIES
f) CIGARETTE SMOKING
In reality, it may include any of the following
 RECURRENT HERNIATED DISC [picture herniated disc]
Meaning that the operated disc has herniated again
 LOOSE DISC FRAGMENT
[picture loose disc fragment]
Implying that a piece of the operated disc was left behind
 INTRATHECAL OR EPIDURAL HEMATOMA [picture
intrathecal or epidural hematoma]
After surgery, blood accumulated inside and/or out of the dural sac
 NERVE ROOT DAMAGE [picture nerve root damage]
 INADEQUATE RELIEF OF THE PRESSURE PRODUCED
AGAINST NERVE ROOTS
 INFECTION OF THE WOUND
 A HOLE WAS MADE INTO THE DURAL SAC
 SURGERY WAS DONE AT THE WRONG LEVEL
If you were not informed of these possibilities and you are having worse
pain, continuous pain, more severe pain or burning pain, it is more likely
than not, that one of the above listed complications may have occurred, and
now you have a more serious complication. [link to complications]
COMPLICATIONS can be:
 PSEUDOMENINGOCELE is a false sac that has formed trying to
contain the spinal nerve roots and the cerebrospional fluid [picture
pseudomeningocele
 ARACHNOIDITIS is an acute inflammation of one of the
meningeal layers that can become chronic and permanent [link to
ARC website] [link to stages of ARC with pictures of inflamed and
clumped nerve roots]
 UNSTABLE SPINE usually resultant from excessive removal of the
support structures of the vertebrae (i.e. laminae, facet joints, etc)
[picture of removed laminae]
 DURAL SAC ECTASIA is an abnormal dilatation of the dural sac
below where the operation was done [picture dural sac ectasia]
 FIBROSIS AND SCARRING as we all heal by scars, four or six
months after laminectomies, scar tissue tends to cover and surround
where the surgery removed bone or ligaments, sometimes
surrounding nerve roots and constricting them producing severe pain,
numbness and weakness in the area corresponding to that specific
nerve root. Removal of fibrosis usually ends up in more scarring
[picture of fibrosis and scarring]

SPONDYLOLISTHESIS is another term for a “slipped vertebra”
that gets out of alignment, producing severe pain when standing or
walking [picture of spondylolisthesis]
WHAT FAILS IN THE ‘FAILED BACK SYNDROME?’
This particular syndrome has evolved from the “Failed back” to the failed back syndrome
and into the “Failed lumbar spine syndrome” a condition that occurs when laminectomies
do not succeed in relieving the patients’ low back pain. The incidence has not been
determined, but frequency has been noted to be between 5% and 40%, indeed a wide
range ( ).The causes are varied and at any one time, one or more may be causing the
reappearance of pain and neurological symptoms after these operations, including
INCIDENTAL DUROTOMY
Usually are due to an unrecognized incidental dural tear during the operation or from
rupture of the repaired, recognized rip of the dural sac. Depending of the amount of
cerebrospinal fluid lost, postural headache and even meningismus may occur with a
bulging mass under the incision. Occasionally, fluid may leak through the suture line,
which can be tested for sugar content with a glucose strip. Ultimate confirmation can be
obtained by and MRI of the lumbar spine. If CSF is contained in the retrospinal tissues,
eventually a soft, thin pseudo-membrane is formed that contains the CSF. Giving rise to
the formation of a pseudomeningocele (figure ), thereafter, if not initially repaired.
Puncture is not, recommended as it may leak CSF, persistently.
LOOSE DISC FRAGMENTS
With an incidence from 3 to 15%, usually occur when a fragment of nucleus pulposus is
carried out of the annulus fibrosus cavity by the grand-jeurs employed to remove the loos
portions of the nucleus. More commonly it happens during this maneuver, but they can
also come out later on when the patient is mobilized. Pain is sharp, severe and localized
to the dermatome corresponding to the compressed nerve root by the 0.5 to 1.4cm fibrous
mass (figure ). Confirmation is again done with an MRI, requiring immediate surgical
re-intervention as the patients are in severe constant pain and may have bladder
dysfunction.
INTRATHECAL AND OR PERIDURAL HEMATOMA
Are serious occurrences. The first type is manifested by severe burning low back pain
with or without radicular symptoms appearing immediately upon patient’s awakening
from the anesthetic. It usually requires considerable dosages of opiates to control it. More
common are the extradural hematomata (figures
), which initially present as with light
to moderate back pain but with moderate to severe paravertebral muscle spasm. Severe
pain and neurological symptoms may appear two or three weeks postoperative, as a result
from the degradation of blood elements and products (leukotrienes and cytokines) that
begin to cross the dural barrier.
NERVE ROOTS CYSTS
Leg pain with minimal back pain, may be caused by postoperative cystic outpouchings
when dural tears occur in the dural cuff that accompany the emerging nerve roots ( figure
) during their intraspinal canal passage. They should be differentiated from the Tarlov or
congenital arachnoid cysts that occur on the same location At myelography, they fill
immediately. Postoperative arachnoidal cysts are formed at the time of surgery when a
small dural tear occurs in this same sheath location, and is not corrected; the arachnoid
that herniates through this dural tear, forms the primary cyst and is usually reinforced by
an outer wall of fibrous tissue. There may be fluid pulsations. In any case the ostium hole
or opening is very small.
EPIDURAL FIBROSIS
Is perhaps the most common of the complications, soon after a laminectomy, acute
inflammatory response is noted around the dural sac and the paravertebral muscles, after
all this is the manner by which healing is accomplished in all living creatures. This
diminishes after the first week ( figure
) eventually the cellular infiltrates give way to
collagen cells deposition that progresses for months eventually compressing the dural sac
or impinging a nerve root. If foreign bodies (surgical, cotton pads) or glues (ADPL,
thrombin, etc.) are left next to the wound the reaction is manifested according to the
nerve root affected.
It is considered usual that all patients have certain degrees of scar tissue 4 months after;
the encircling of a nerve root produces localized pain and sensory disturbances as it
elicits a traction effect on the root. Nerve root displacement is frequently caused by a
recurrent herniated disc; however the differential diagnosis is difficult and requires MRI
study with gadolinium in order to enhance the scar tissue by the transfer of the dye from
the intravascular to the interstitial tissue compartments as it could be due to inflammation
or scarring, whereas disc usually does not enhance. High dose contrast (0.3mmol/kg) has
been demonstrated to increase the conspicuity of the disc.
INSUFFICIENT DECOMPRESSION
This may usually is seen within the lateral foramina stenosis compressing the nerve root
and may be caused by recurrent bone growth within the lumen, soft tissue, or even bone
when remnants of bony spurs are not removed. Within the spinal canal, central stenosis
may be due to a hypertrophic ligamentum flavum or short pedicles, in which case, wider
decompression may be necessary, such bilateral laminotomy or lateral foraminotomy.
RESIDUAL OR RECURRENT DISC
A portion of the herniated disc was left loose, or whatever was left, herniated again.
MECHANICAL INSTABILITY
The lower portion of the spine lacks the mechanical stability to support the weight of the
whole torso.
PSEUDOARTHROSIS
A fusion that failed to make one bone out of two, leaving two bony surfaces touching
each other. That produces pain mostly when standing or sitting up.
INFECTIONS
Can occur in the soft tissue (cellulitis, fasciatis (figure), as an epidural abcess or as
meningitis with delayed clinical manifestations for up to one month. Discitis ( figure )
may also be present and
SURGERY AT THE WRONG LEVEL;
Indeed the surgeons nightmare can occur as sometimes the S1-S2 space is mobile or the
L5-S1 space is non-mobile misleading the surgical team. The best way to avoid
opoerating in the wrong space is my confirming the positiopn of metal object in the
intendined space to operate, by taking a radiogfraph or by two-exposure fluoroscopy.
ARACHNOIDITIS
Occurs in about 12 to 20% of spinal operations.
You are referred to the website www.arachnoiditis.com
SPINAL STENOSIS
Repeated operations may produce both axial and radicular pain that may be caused from
progression or overgrowth of a previous spinal fusion, or hyperthrophic osteophyte which
may coexist with peridural scarring compressing significantly the dural elements.
Although bony and ligamentum compression may be mechanically reduced, pain relief
may be minimal.
YOU HAVE BEEN TOLD THAT YOUR BACK IS
UNSTABLE [picture mechanisms involved in
developing an unstable spine]
This may or may not be true. If you have not had surgery, it may be that you
have on of several conditions that some individuals are born with such as
“occult spina bifida, lumbarizations of S1” meaning that in stead of the sacral
vertebra #1 been solidly joint with 4 others below, is flexible, like the
vertebra of the lower back, that makes it unstable because that S1 vertebra is
not made to support the weight of the whole body, so it produces pain. The
opposite can happen with L5 vertebra been solidly fused with S1, also called
“sacralization of L5, so there is not a functioning disc at that level. The
manifestation of either condition is pain when you stand up or walk for a
while.
LOOSE DISC FRAGMENT
Someone did not do a good job, some time or some where, because what this
means is that a loose fragment of disc was left loose inside of the disc
(annulus fibrosus) and was spilled back into the canal and it s now
compressing one of the nerve roots, very similar as before you had the
surgery when you had sciatica. Unfortunately there is not much that can be
done other than going in there and removing it after an MRI is taken to
confirm the diagnosis. Re-operation usually means more fibrosis and
scarring, but it has to be done, as the pain is usually extreme.
INSUFFICIENT DECOMPRESSION
This usually represents that there was a certain degree of narrowing of the
spine, whether by the herniated disc or by enlarged joint of the spine (facet
joints). When the surgeon goes in it is implied that he is going to remove all
constraining elements; however, sometimes, more often than not the do not
remove enough bone, so the canal remains tight and the patient continues to
have low back pain. The concern expressed in the prior paragraph also
applies to this condition.
HOW TO AVOID THESE COMPLICATIONS
A.
B.
C.
-
Not to have surgery
Only have it if strictly indicated when suddenly you are
unable to walk
lose bladder and or bowel control and
if you have unremittent pain not treatable by the usual means
Discuss all these possibilities with your surgeon
Ask what does he/she do to prevent them
What is the rate of these complications?
Get a second opinion from a specialist of different discipline
Before a patient agrees to have spinal surgery, the patient has to be assured
that whatever is causing his/her pain is going to go away. There is no point
of having an expensive operation if the pain is going to be the same or
worse, since pain is the leading symptom and the reason why most patients
go to see the doctor you have to make sure that the pain is going away.
Check the medical literature [link to the medical literature references]
If you find yourself in a quandary in the middle of the
above circumstance and you are not receiving
straight answers from your doctors you may consider
sending an abbreviated medical history (in
chronological order) and all X-ray films for expert
interpretation and review giving you the true
diagnosis and what it means.
Perhaps what you need is another study (MRI) [link to
picture MRI], this time with the correct indication.
Please do not accept any more MYELOGRAMS (unless
you have metal in your body).
DO you realize that Americans have the same RATE of low back pain as
citizens from most industrialized countries; nevertheless, back surgeries
are performed from 7 to 10 times more frequently in the USA. The first
thought that comes to your mind is well that is because we have better
medical care. Unfortunately, that is far from the truth, the monetary
incentive is the real indicator. It induces surgeons
- to operate even when not indicated
- to perform a more extensive surgery, even if it is not necessary
- to implant expensive hardware (titanium), even when it is not
indicated
The surgeons, the hospitals and the manufacturers rip the gains of this
bonanza that frequently results in more patients with severe pain and
disability that are given this generalized diagnosis.
You asked for help, because you had back pain, you were told:
- to exercise it, but it only got worse
- to have some injections, but it did not improve
- to have surgery, but you still have pain
So, after innumerable procedures, another operation you were told that
now you belong to the new patient population group of the ‘disabled’ and
were distinguished with the label of ‘FAILED BACK SURGERY
SYNDROME’.
The implication is that the patient’s back failed, where as in fact it was
the operation or the therapeutic regimen chosen for you what failed. After
surgery you were literally “dumped” into a pain clinic where you will
have injections, narcotics, exercises, psychoanalysis and bad news from
now on. Your bladder dribbles, your bowel is always constipated and
your sex life has gone to the dogs, you have lost your job, your health
insurance and most of your financial resources. Now What? [link to
disclaimer, without accepting disclaimer they cannot go on] [link to
address and info where to send records and films for review]
J. Antonio Aldrete, MD, MS [link to CV]
If you want to establish a patient doctor relationship please
call 205-968-0068 for further information.
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