label is unhelpful

How useful is it to label a set of complaints as failed back surgery syndrome or post-discotomy syndrome? My view is that, far from improving a patient's condition, such a label may even play a part in its deterioration. Even the authors of articles who use these diagnostic terms admit that they are better avoided since they do not help to identify a cause or a treatment. After all, the only characteristics that these patients share are that they have been operated on for back pain and that non-specific back related complaints returned at some point after the operation.^1-3 I prefer the term non-specific back pain because this provides us with a sound starting point in our search for a diagnosis, treatment, and prognosis.⁴

How can we best help patients in a predicament like this? Operation on a herniated disc immediately relieves leg pain in some 80% of patients. Annoyingly, complaints return or remain after surgery in 10-40% of cases, regardless of the technique used. Unfortunately, we have not yet found a way of predicting this recurrence. In more than half of these patients, the reasons for the recurrence remain unclear. The most treatable causes are recurrence of the hernia and instability of the spine, although treatment of spinal instability is controversial.¹,² Epidural fibrosis (or scar tissue) is an often cited cause, but this does not seem to be linked directly with either pain or disability. Some evidence indicates that psychological factors such as anxiety or problems with work and disability have a major role.¹

Meeting patients' needs

Qualitative research among patients with chronic back pain shows that they have a great desire for an explanation, a diagnosis, instructions, referral to a specialist, and, above all, for their complaints to be taken seriously.⁵ Sadly, we do not offer much to fulfil these expectations. In most cases there is no real diagnosis and no specialist who can simply stop the pain, and a new operation is often counterproductive. In one patient series, almost 80% of the patients who had repeat surgery reported dissatisfaction with the results in the long term, despite apparent initial success.¹,²

Therefore, efforts have to be directed at restoring normal everyday life as far as possible. Contrary to the belief of many patients, conservative treatment or no treatment does not lead to more complications but to fewer. Our fear of paralysis and disability is usually based on an appealing but rather simplistic, mechanistic view of disc herniation: the disc has burst out of its packaging and the nerve root has become wedged between the disc fragment and the vertebra. However, many people have herniated discs without noticing any symptoms or signs.

Remaining active or doing physical exercises will not lead to a relapse or an increase in neurological symptoms. On the contrary, this can have significant beneficial effects.⁶ A customised rehabilitation programme led by a physiotherapist can build up self confidence. Although there is some evidence that exercise is an effective therapy after an operation on a herniated disc, I would prefer rehabilitation to be organised in a multidisciplinary setting with a specialist in back pain, a psychologist, and a physiotherapist working as a team.¹ Granted, no evidence is available that this is more effective than other rehabilitation measures, but the combined approach has the advantage of dealing with physical and mental issues at the same time.