Treatment options for Failed Back Surgery SyndromeJune 15, 2018
There is much debate in the medical community as to why there are so many patients who decided on a spinal surgery and end up worse off after the procedure.
One of the concerns is that the patient was sent to a surgery they did not need or were too complex for the problem the patient was facing.
At the Magaziner Center for Wellness we present non-surgical options for chronic, difficult to treat back pain.
Options we provide include regenerative medicine such as stem cell therapy and prolotherapy. We can perform these procedures on patients who have already had back surgery and it failed to meet their expectations, in terms of their problems of pain and movement. We can also perform these procedures on patients who wish to avoid spinal surgery all together.
Do patients with failed back surgery syndrome want more back surgery?Doctors support use of multiple surgeries.
A study in the Journal of medicine and life with the title “Diagnosis and operatory treatment of the patients with failed back surgery caused by herniated disk relapse,” said this:
“Repeated surgery is a viable option for patients who have clinical manifestations of recurrent disc herniation . . Supplementing repeated discectomies (surgeries to remove disc material) and decompression with (spinal) fusion provide superior clinical outcomes, especially in patients with clinical and radiological signs (an MRI) of lumbar segment instability.”1
According to many studies, including one in the journal: Spine, suggest that repeated surgery should be avoided in these patients but also pain medications as well as there is none or little evidence that these two “solutions” will offer the patient comfort.2
The keywords above: repeated surgery, spinal fusion, spinal instability – that is a lot of procedures.
Nancy Epstein MD, Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, documented in her research that of 274 patients, 17% with cervical/lumbar complaints seen in first or second opinion over one year were recommended to “unnecessary” spine surgery (e.g., defined as for pain alone, without neurological deficits, or significant MRI finding).
The paper published in the journal Surgical Neurology International, found that 69 (44.5%) of the 155 second opinion patients seen over a 14-month period were told by outside spine surgeons that they needed surgery; the second opinion surgeon found those operations to be unnecessary.
Increasingly, patients, spine surgeons, hospitals, and insurance carriers should not only be questioning whether spinal operations are “unnecessary”, but also whether they are “wrong” (e.g., overly extensive), or “right” (appropriate). Of 183 second opinions seen over 20 months, the second opinion surgeon documented that previous spine surgeons recommended were “unnecessary” (60.7%) or the “wrong” surgery (33.3%).3
Unnecessary surgery because of MRI?
At the Magaziner Center for Wellness, we tell our patients that we rarely if ever rely on an MRI. When the patient expresses curiosity about our decision after a long history of getting films, we tell them that in our opinion these tests are a waste of money.
How many times do we see a patient can come in with a big file of films and scans that cost them a lot of money out-of-pocket, and typically, there will be no useful information that will help us get the patient to their treatment goal of being pain-free. A skilled physician can make a more accurate determination of a pateint’s diagnosis and treatment plan with a careful physical examination and history.
Unfortunately, there is a certain appeal to the patient to get an MRI, especially the athlete who thinks it is part of the normal process of treatment. It is sometimes difficult to get the patient to understand that when they get an MRI there will be a recommendation for a surgery that many times is unnecessary.
What’s better? A physical examination or MRI?
Recent research tried to assess the diagnostic accuracy of history taking for the presence of lumbosacral nerve root compression or disc herniation on MRI in patients with sciatica. A total of 395 adult patients with severe disabling radicular leg pain of 6-12 weeks duration were included.
Lumbosacral nerve root compression and disc herniation on MRI were independently assessed by two neuroradiologists and one neurosurgeon blinded to any clinical information. What the study showed was: A few history items (simple questions) had significant diagnostic value and the diagnostic accuracy.4
Unnecessary surgery based on MRI
British Doctors and specialists at Southampton General Hospital in England noted in their own research that their own professionals could not agree on what the MRI said in diagnosing lumbar disc disease.
“we found in our study that there is wide variation in diagnosing lumbar disc disease between the Orthopaedic Surgeons and the Radiologists at our institution…Due to this amount of inaccuracy, it is risky to comment on degenerate disc disease on a plain radiograph alone. Therefore MRI scan should only be used to comment on the disc diseases of the low back, as plain radiographs are unreliable.”5
Before you consider the surgical option based on an MRI a consultation with a doctor trained in non-surgical treatment of ligament and tendon injuries, such as Prolotherapy and PRP (Platelet Rich Plasma) Therapy, may be an option to surgery.
Repeated surgery and pain medications are not the answer.
The sudden burst of activity in stem cell therapy and Platelet Rich Plasma therapy research is do in part because of the increasing number of joint replacement and surgeries performed and the rising numbers of failed procedures.
Treating Patients With Prolotherapy Stem Cell Therapy
The problem of Failed Back Surgery is why doctors are looking to help patients avoid spinal surgery by researching how stem cells may reverse degenerative disc disease.
Research from Italy points out that conservative (physical therapy, disease modifying medications, minimally invasive procedures) and invasive procedures (surgery) are not capable of restoring the degenerative alterations of the disc. This is because they only help relieve the symptoms and/or slow down disc degeneration.
The potential use of stem cells, however, for treating intervertebral disc degeneration, has been promising with studies showing proof of disc matrix reconstitution, increased cell viability and tissue regeneration in several experimental settings.6 In simple terms – repair.
In July 2017, doctors wrote in the journal Internal Orthopedics that intradiscal bone marrow concentrate (stem cell therapy) injections were a viable treatment for low back discogenic pain and could be presented as an alternative to surgery. A total of 26 patients suffering from degenerative disc disease and candidates for spinal fusion or total disc replacement surgery were injected with 2 ml autologous bone marrow concentrate into the nucleus pulposus of treated lumbar discs. There were no adverse events related to marrow aspiration or injection. This study provides evidence of safety and feasibility of intradiscal bone marrow concentrate therapy.
Patient improvement and satisfaction with this surgical alternative supports further study of the therapy.7
Patients who had already failed two conservative treatments or already had failed back surgery were helped by Prolotherapy
Researchers in the United Kingdom looked at the use of prolotherapy in patients who had failed to respond to conservative approaches including spinal manipulation and physiotherapy in (UK National Health Service) back pain clinic settings. These patients had longstanding and often severe pain and disability.
After a “short” bout of Prolotherapy – treatments 3 injections over a 3 to 5 week period. they confirmed that 91% of respondents were better or not worse off after 12 months. 8
This despite only three injections over a 3 to 5 week period.
Studies such as the one cited above have been circulating for years. Similar results were achieved in a 2005 study publish in the medical journal Pain Physician. In this study the researchers took on the difficult cases: “Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery.”
Here is what the researchers reported:
“Injection therapy of painful enthesopathies (soft tissue attachments to the bone, ie ligaments and tendons) can provide significant relief of axial pain and tenderness combined with functional improvement, even in “failed back syndrome” patients. Phenol-glycerol prolotherapy provides better and longer lasting relief than injection with anesthetics alone. Prolotherapy provides over six months of relief for some patients but generally provides relief for only a few months. However, most patients described good to excellent relief, felt that the injections had been beneficial, and requested additional injections for recurrent or residual focal pain.” 9
One of the most important things to note is that the patients in these two studies were patients who had already failed two conservative treatments or already had a surgery.
Do you have questions about this article or to see if you are candidate for treatment, contact the Magaziner Center for Wellness
1. Bodiu A. Diagnosis and operatory treatment of the patients with failed back surgery caused by herniated disk relapse. J Med Life. 2014 Oct-Dec;7(4):533-7.
2 Amirdelfan K, Webster L, Poree L, Sukul V, McRoberts P. Treatment Options for Failed Back Surgery Syndrome Patients With Refractory Chronic Pain: An Evidence Based Approach. Spine. 2017 Jul 15;42:S41-52.
3. Epstein NE. Are recommended spine operations either unnecessary or too complex? Evidence from second opinions. Surg Neurol Int. 2013 Oct 29;4(Suppl 5):S353-8. doi: 10.4103/2152-7806.120774. eCollection 2013.
4. Verwoerd AJ, Peul WC, Willemsen SP, Koes BW, Vleggeert-Lankamp CL, El Barzouhi A, Luijsterburg PA, Verhagen AP. Diagnostic accuracy of history taking to assess lumbosacral nerve root compression. Spine J. 2013 Dec 7. pii: S1529-9430(13)01964-5. doi: 10.1016/j.spinee.2013.11.049.
5. Weiner BK, Patel R. The accuracy of MRI in the detection of Lumbar Disc Containment. Journal of Orthopaedic Surgery and Research 2008, 3:46
6 Vadalà G, Russo F, Ambrosio L, Papalia R, Denaro V. Mesenchymal stem cells for intervertebral disc regeneration. J Biol Regul Homeost Agents. 2016 Oct-Dec;30(4 Suppl 1):173-179.
7 Pettine KA, Suzuki RK, Sand TT, Murphy MB. Autologous bone marrow concentrate intradiscal injection for the treatment of degenerative disc disease with three-year follow-up. International Orthopaedics. 2017 Jul 26:1-7.