"Failed back surgery syndrome"

Short abstract

An inappropriate diagnostic label may exacerbate the discomfort of patients who develop persistent and disabling symptoms after back surgery

Every general practitioner has one—a patient who has had back surgery but hasn't improved. Around 2000 cases of failed back surgery syndrome are produced each year in the United Kingdom.^1-3 This is an uncomfortable statistic, and it is an uncomfortable condition to manage. Patients are often young and were previously active but now face chronic pain for years. They come from the surgeons but are no longer surgical candidates. They have been through the gamut of orthopaedic, neurological, and radiological opinions followed by physiotherapy, occupational therapy, and possibly clinical psychology, funnelling them inexorably towards the pain clinic. Unfortunately, they fare badly there too, with just over one in three patients achieving more than 30% pain relief.

I know about this dreary path at first hand. Nowadays, we may increasingly be questioning the advisability of surgery for prolapsed disc, but not operating can also produce long term disability. Comparison of the UK rate of spinal surgery with that in other countries shows that UK surgeons are not sharpening their scalpels to the ringing of cash tills. Yet 5-10% of patients who have back surgery return home without relief of their radicular pain.²,³ Worse still, after about six months, the pain may be showing an unpleasant whiff of neuropathy.

Figure 1.

False colour nuclear magnetic resonance image of prolapsed disc

Credit: MEHAU KULYK/SPL

Personal view

I practised general medicine in both England and Germany. When the radicular pain returned after my microdiscectomy, I battled for months to cope with ward work while seeking out an unoccupied bed in a quiet corner for periodic breaks. The availability of beds, in Germany at least, makes medicine seem the perfect occupation for someone with failed back surgery. I returned to the neurosurgeon, who did computed tomography, pronounced that the prolapse had not recurred, and told me it would take more time. Despite twice weekly physiotherapy and utmost care with all physical activities, I gradually worsened and developed bladder problems.

Only after many consultations and investigations did I pick up a book and read about Postdiskotomie-Syndrom. I then began to understand that, although the nerve roots were not damaged directly by the surgery, they were now encased in a web of scar tissue causing pain and spasm every time this was tweaked enough by movements of the spine and legs.

Diagnosis

But I am also caught in a web myself, resulting from the lack of awareness of what is actually not such a rare condition. Having had access to the German diagnosis, I may have had a head start on my fellow sufferers in the United Kingdom. Here, a major difficulty is the uncritical use of the label "low back pain" to cover all patients with and without radicular pain, irrespective of possible aetiology. This confuses patients, therapists, and doctors alike. The impression is of a lack of precision in both diagnosis and treatment. But failed back surgery syndrome is also an unfortunate term, implying failure of the surgeon or possibly of the patient. In most cases, neither is true.

Despite the plethora of investigations that can be used for such a condition, the diagnosis remains essentially clinical. Magnetic resonance imaging and computed tomography are necessary to rule out lesions amenable to surgical intervention, but they cannot determine whether the intraspinal scarring is causing the symptoms. Neuropathic pain may not always have a burning quality, but other recognisable features are often present—for example, delayed summation of pain after provocation, the extension of pain perception beyond dermatomal boundaries, and allodynia (pain resulting from touch alone).

Support for patients

In many ways failed back surgery syndrome resembles multiple sclerosis: the conditions have the same range of symptoms of pain and numbness, weakness and spasm in the limbs, and bladder and bowel difficulties. But whereas some neurological units offer specialist expertise in treatment and lifestyle support for people with multiple sclerosis, patients with failed back surgery syndrome are left outside the door. In terms of numbers, there is roughly one person with failed back surgery syndrome for every two with multiple sclerosis.

After four years I still haven't found appropriate rehabilitative support in the United Kingdom. Pain management programmes, where well-intentioned encouragement of generic measures is the rule, generally fail to take into account the real danger of further nerve damage and a permanent increase in symptoms. I have learnt to be wary of enthusiastic physiotherapists. Even in Germany, where I participated in a rehabilitation programme, this was very much batch processing, with little attention to variations between patients.

Summary points

Surgery for prolapsed disc fails to relieve pain in 5-10% of patients

Patients with failed back surgery syndrome face increasing disability as well as chronic pain

The condition has fallen into a no-man's land between surgery and medicine

Rehabilitative medicine is poorly developed, focusing mainly on pain relief

Patients with failed back surgery syndrome live with the constant anxiety of relapse and steady deterioration of a range of neurological symptoms, yet current medical management focuses narrowly on relieving pain. This is another strand in the web in which patients are caught: good pain relief brings the illusion of improved physical ability. However, for many patients, after a brief honeymoon period pain, spasm and weakness appear at a lower activity level, and the web tightens to immobilise the ensnared nerve roots (and patients) even more.