The wrong level of surgery is performed
In some rare situations, the wrong level of surgery is performed. This occurs because while the lumbar spine, thoracic sine, and cervical spine each have their own set of vertebra, most of them look the same. To identify these vertebra, careful observation of the anatomy of the spine from the intraoperative X-rays need to be performed.
There are many factors that can make vertebral levels appear distorted. Some patients have congenital anomalies that can put the count off in determining levels. 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. Hopefully, these errors are caught in the operating room. If the surgery was not a success leading to a failed spinal surgery, a new MRI or CT scan can reveal the error of the incorrect level.
Neuropathic pain is present but is not recognized
Neuropathic pain is the most common surgical diagnostic dilemma that spine specialists face. This pain after neck surgery is pain generated as a result of internal injury to the nerve root. This condition occurs from compression or stretch of a nerve. 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, failed back surgery syndrome symptoms can persist.
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.
Injections for spine pain 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.
Following a failed spine surgery, treatment of chronic pain management would include medications and neck surgery therapy and might include neurostimulation.
The initial diagnosis made was wrong
Though rare, 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. A careful work-up will be needed once it is confirmed that a patient has failed neck surgery syndrome. The underlying condition 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.
The original spine surgery was not performed perfectly or correctly
Sometimes during surgery, problems can occur that will result in spine pain even after the surgery has been completed. An inadvertent tear of the dura could expose nerve roots that can be damaged by subsequent rough handling. Dural leaks in the spine are rare, but can occur. A screw could be placed in a position that can irritate a nerve and cause pain in the leg or arm. Fusion failures leading to failed back surgery 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. 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. 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.
The patient did not follow immediate post-operative restrictions (smoking cessation, activity restriction, activity overstimulation)
While failed spine surgery syndrome (neck) doesn’t happen often, when it does, it’s important to look at each and every cause. 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 neck surgery syndrome and corrections
For additional resources on failed neck surgery syndrome, please contact Dr. Donald Corenman, spine specialist and neck doctor serving the Vail, Aspen, Denver and Grand Junction, Colorado communities.