Failed Back Surgery | Spine Specialist

An Overview of Failed Back Surgery of the Lumbar Spine

Many individuals undergo spinal surgery with excellent results. The success rate with most surgeries is about 90%. When surgical results are not what they should be, a new workup needs to be completed to find out the source of the continuing symptoms. Once the exact cause of the back pain has been found, treatment for pain for a failed spine surgery of the lumbar spine can be sought.

Common Causes of Failed Back Surgery

Pseudoarthrosis

Failure of fusion surgery is a failure of the bones to unite. This is called a pseudoarthrosis or “false joint.” Pseudoarthrosis can occur even in the best of circumstances and in the best hands but should be uncommon. This failure of fusion however can occur as a higher percentage under some circumstances.

Instrument fixation of the two bones to be united using screws and plates or rods is critical to prevent motion. Motion prevents the bone cells from uniting the two surfaces. A construct that is flexible or weak can contribute to pseudoarthrosis.

Paramount in fusion surgery is preparation the graft bed or the bone surfaces so that nothing impairs the fusion. Poor preparation can lead to fusion failure.

The choice of graft materials is important. Use of allograft (donor bone) has a lower fusion success rate than autograft (your own bone). The use of PEEK spacers (plastic spacers) can be useful or detrimental depending upon the circumstances. The use of bone morphogenic protein can significantly increase the fusion rate and the speed to fusion under the right circumstances.

The CT scan (on a 64 slice or greater scanner) and the flexion-extension x-rays are the mainstay to diagnose a pseudoarthrosis. In correctly chosen cases, surgical repair can remedy the problem.

Incomplete or recurrent compression of a nerve has occurred

Surgery to relieve buttocks, arm and shoulder or leg pain is called a decompression surgery. It may or may not be accompanied by a fusion surgery. If buttocks pain, leg pain, arm pain or posterior shoulder pain is still present after surgery or is relieved only temporarily after surgery, the nerve may not be fully decompressed or may have developed recurrent compression.

An example is a foraminotomy either in the neck or the lower back. A complete decompression will yield pain relief but if the vertebral level collapses after the decompression, the nerve will be compressed again and the pain will recur. Another example is a microdiscectomy for disc herniation. Pain relief for three weeks and then return of pain could indicate a recurrent disc herniation.

An MRI should reveal this condition.

Neuropathic pain is present but is unrecognized

Neuropathic pain is pain generated as a result of internal injury to the nerve root. This condition occurs from compression or stretch of a nerve. This is the most common surgical diagnostic dilemma that spine surgeons face. Diagnosis can only be confirmed by a successful surgical decompression with continued nerve pain and no further compression based upon a new post-operative MRI.

Before the initial surgery, a physical examination can typically identify the nerve involved. Imaging (X-ray, CT scan or MRI) will confirm the nerve compression. A nerve root block will even relieve the pain generated by the injured nerve. A successful surgery to decompress the nerve can be performed. A post-operative MRI will note a successful surgery where the nerve is free from compression. In spite of all of this, the pain remains

This is an unfortunate case of neuropathic pain. The nerve was damaged by the original compression (herniated disc, lateral recess or foraminal compression) and the surgery successfully decompressed the nerve but the nerve itself did not heal.

An injection can temporarily relieve the pain, as even an injured nerve will stop pain conduction under the proximity of a numbing agent like Lidocaine or Marcaine.

Treatment is chronic pain management, which would include medications and therapy and might include neurostimulation.

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(Please keep reading below for more information on this condition.)

Wrong level lumbar spine surgery is performed

This situation is highly unusual but not unheard of. There are five vertebrae in the lumbar spine, twelve in the thoracic spine and seven in the cervical spine. Most of them look the same. To identify these vertebra, careful observation of the intraoperative X-rays need to be performed but there are many factors that can make vertebral levels appear distorted. Parallax of the image, very large body habitus making visualization difficult, poor x-ray technique and malfunction of equipment can occur to conceal the levels. Some patients have congenital anomalies that can put the count off in determining levels. Hopefully, these errors are caught in the operating room. If the surgery was not a success, a new MRI or CT scan can reveal the error of the incorrect level.

The wrong initial diagnosis originally was made

If a number of potential pain generators exist and the history and physical examination does not lead to a specific diagnosis, an error of wrong diagnostic site can occur. Without an obvious source of pain, pain generators should be investigated,

Careful identification of the pain generators using diagnostic injections can make the proposed surgical success rate higher. For example, a nerve could have been compressed at one level but not causing pain and at another level the painful pinched nerve is not recognized and not surgically addressed.

A careful work-up after an unsuccessful surgery can reveal this condition.

The original surgery was not performed perfectly

There are rare times that problems can occur during surgery. A screw could be placed in a position that can irritate a nerve and cause arm or leg pain. An inadvertent tear of the dura could expose nerve roots that can be damaged by subsequent rough handling. Fusion failures can occur from incomplete preparation of the fusion surfaces, improper placement of graft or of the wrong choice of graft material.

MRI and CT scans can potentially reveal some of these problems and the use of an intraoperative CT scan (the O-arm– see website) and intraoperative monitoring can prevent some of these errors.

The patient did not listen to or was not given the post-operative expectations (expectations too high)

Certain spine surgeries come with limitations that need to be understood and abided by. For example, while a one level fusion of the lumbar spine comes with no restrictions, a two level lumbar fusion has restrictions of impact and load. Three levels and more have further restrictions. Not following these restrictions can possibly cause further degeneration at levels higher in the spine.

Fusion of the lumbar spine does typically relieve pain but does not commonly relieve all pain. Pain is typically reduced by about 2/3rds. If the patient does not understand that fact and is disappointed regarding the results, he or she might not have been educated sufficiently and expectations were too high.

The patient did not follow immediate post-operative restrictions (smoking cessation, activity restriction, activity overstimulation)

There is a responsibility that the patient needs to embrace to undergo spine surgery. Patients need to quit smoking as the nicotine in tobacco retards fusion cells. Patients that do not listen to restrictions or go back to hard work/ lift and bend too soon after lumbar fusion can disrupt the healing of the bone cells. Patients that mountain bike or ski immediately after cervical ACDF can reduce the chance of healing.

Individual Examples of Failed Lower Back Surgery Syndrome and Corrections

Missed Diagnosis – Far lateral Lumbar Disc Herniation

For additional resources on failed back surgery of the lumbar spine, please contact the Vail, Aspen, Denver and Grand Junction, Colorado area office of back doctor and spine specialist Dr. Donald Corenman.

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Donald Corenman, MD, DC

Average rating:

81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Failed Back Surgery Syndrome – Lower Back