It may be more challenging to get a spinal surgery these days. For some people it may be even more challenging to recover from it once they do have it. In this article I hope to share with you three main thoughts from recent research.
- Who is at risk for failed back surgery
- What happens to put people at risk for failed back surgery syndrome before the surgery?
- What can be done in situations for failed back surgery syndrome after the surgery?
I have made it a point throughout this website to display my great admiration for surgeons. I went to medical school to become a surgeon. As I saw more and more failed surgeries I decided to change my practice over to providing non-surgical methods. There are very many people who have had very successful spinal surgeries, My article here will help provide information on alternatives.
Pain and fear of movement following spinal surgery
Let’s look at two studies, seven years apart, from the same learning institute. The research concerns pain and fear of movement following spinal surgery and which patients would be at greater risk for poorer recovery.
From 2011: Patients with back pain have many concerns and fears when it comes to being able to move pain-free. Surgery is supposed to take care of this fear. Researchers from the University of Gothenburg, Sweden (1) followed 97 patients after their spinal disc surgery looking for a post-surgical occurrence of kinesiophobia “fear of movement,” a tell-tale sign of unsuccessful back surgery. What they found was surprising.
- Half of the patients suffered from kinesiophobia 10-34 months after surgery for disc herniation.
- Prior to surgery these patients were already classified as more disabled, had more pain, more catastrophizing thoughts, more symptoms of depression, lower self-efficacy, and poorer health-related quality of life than patients.”
For many whom surgery would seemingly be most helpful, the surgery itself did not reverse their problems and made their fear of extremely painful movement worse
Seven years later, 2018. A different team of researchers from the University of Gothenburg, Sweden (2) recruited a study in 2016 which they hoped would help patients following spinal surgery with problems of health-related quality of life, back and leg pain intensity, pain catastrophizing, kinesiophobia, depression, and anxiety. In 2018 they published their findings:
“A high proportion of the patients did not reach the WHO (World Health Organization) recommendations on physical activity and are therefore at risk of poor health due to insufficient physical activity. We also found a negative association between both fear of movement and disability, and the number of steps per day. Action needs to be taken to motivate patients to be more physically active before surgery, to improve health postoperatively. There is a need for interventions aimed at increasing physical activity levels and reducing barriers to physical activity in the prehabilitation phase of this patient group.”
In November 2019, (3) another study confirmed these findings:
“Depression and fear of movement were more important predictors of the execution of activities of daily living and participation in social life compared to morphological (internal structure damage) markers. Elevated depressive symptoms and fear of movement might indicate limited adaptation and coping regarding the disease and its consequences.”
Opioids before surgery leads to great risk of failed back surgery syndrome and failure of spinal cord stimulators.
Many patients choose to have spinal surgery because they do not want to spend a lifetime on painkillers or opioids. As these people wait for their surgery, many find themselves in need of more medications to get them to the surgery. This study from October 2020 (4) demonstrates how improper patient selection can lead to a medical disaster.
In this study, doctors wanted to know why spinal cord stimulation (SCS), while an an effective treatment in failed back surgery syndrome, may not work for everyone. Specifically people who were on opioids prior to the back surgery and the implantation of the spinal cord stimulator following failed back surgery.
- What they found was a higher preimplantation opioid doses associated with unsuccessful spinal cord stimulation suggesting the need for opioid tapering before implantation. With continuous SCS therapy and no explantation or revision due to inadequate pain relief, 39% of failed back surgery syndrome patients discontinued strong opioids, and 23% discontinued all opioids. This indicates that SCS should be considered before detrimental dose escalation.
“ACTION NEEDS TO BE TAKEN TO MOTIVATE PATIENTS TO BE MORE PHYSICALLY ACTIVE BEFORE SURGERY”
The main finding was that the back pain patients needed to become more physically active before the surgery. In our office we achieve these results with stem cell therapy and platelet rich plasma therapy which I describe below.
Here are the findings of why people need to be more active: NOTE, the average age of the patient was 46.
- People with severe low back pain are at higher risk of poor health. Patients scheduled for lumbar fusion surgery are assumed to have low levels of physical activity.
- In 118 patients, waiting for lumbar fusion surgery (63 women and 55 men; mean age 46 years). Physical activity expressed as steps per day and total time spent in at least moderate-intensity physical activity was assessed. The data were compared to the World Health Organization (WHO) recommendations on physical activity for health.
- Ninety-six patients (83%) sent to spinal surgery did not reach the WHO recommendations on physical activity for health, and 19 (16%) patients took fewer than 5000 steps per day, which indicates a sedentary lifestyle. On a group level, higher scores for fear of movement and disability were associated with lower numbers of steps per day.
If you are afraid to move before the surgery, it may get worse after the surgery.
A reason physiocal therapy did not help
This is why training in post-surgical coping skills has received a lot of attention from the medical learning institutes. Doctors began examining a cognitive behavioural-based physical therapy, where a physical therapist would intervene and change the therapy strategies to address fear of extreme pain with back movement. Unfortunately doctors at the University of Washington published a study (5) suggesting that another problem needed to be addressed: “That physical therapists self-perceive a lack of knowledge, skills, and time to provide this intervention.”
Once the physical therapists were trained however, results from a combined research team from Vanderbilt University Medical Center and John Hopkins (6) suggest that a targeted cognitive behavioural-based physical therapy program may result in significant and clinically meaningful improvement in postoperative outcomes. A program that clinicians can recommend for patients at-risk for poor recovery following spine surgery.
Older patients opting out of second surgery.
Why even send a patient who has episodes of depression and catastrophizing thoughts to surgery? When I was in medical school, I did surgical research and assisted in the operating room much more than my classmates. By the time I had finished medical school and internship (where I spent as much time as possible doing orthopedic procedures) I had seen too many surgical failures including my own shoulder surgery. Worse was when the first surgery clearly failed, the patient was offered a second surgery to fix the first one. Older patients usually refused the second surgery, later documented in the research: “The likelihood of repeat surgery for spinal stenosis declined with increasing age and other diseases, perhaps because of concern for greater risks.” (7) There may have been less surgeries because older patients were not able to have them.
Patients with extended periods of pain “should be informed that the likelihood of re-operation following a lumbar spine opertaion is substantial.” 2007-2020
- A well cited 2007 (8) study wrote: Patients with extended periods of pain “should be informed that the likelihood of re-operation following a lumbar spine operation is substantial.”
- In 2010, another study (9) noted “Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved.” Not solved is polite way of saying the patient remains in significant pain. The segment above the fusion, and the one below then take the brunt of the movement stresses and often break down.
On August 3, 2016 the New York Times presented this evidence AGAINST spinal fusion surgery:
Spinal Fusion Surgery was no better than alternative nonsurgical treatments, like supervised exercise and therapy to help patients deal with their fear of back pain. In both groups, the pain usually diminished or went away.
The studies were completed by the early 2000s and should have been enough to greatly limit or stop the surgery, says Dr. Richard Deyo, professor of evidence-based medicine at the Oregon Health and Sciences University. But that did not happen, according to a recent report. Instead, spinal fusion rates increased — the clinical trials had little effect.
Spinal fusion rates continued to soar in the United States until 2012, shortly after Blue Cross of North Carolina said it would no longer pay and some other insurers followed suit.
“It may be that financial disincentives accomplished something that scientific evidence alone didn’t,” Dr. Deyo said.
Other operations continue to be reimbursed, despite clinical trials that cast doubt on their effectiveness.
In April 2020, a study titled: “The Long-Term Reoperation Rate Following Surgery for Lumbar Stenosis,” found these statistics for lumbar stenosis surgery:(10)
- The overall cumulative incidence of reoperation was:
- 6.2% at 2 years,
- 10.8% at 5 years and
- 18.4% at 10 years.
- The cumulative incidence of reoperation was 20.6%, 12.6% and 18.6% after anterior fusion, posterior fusion, and decompression, respectively, at 10 years postoperatively
Sowhat are our options? Please see may articles on the following subjects:
Do you have questions? Ask Dr. Darrow
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1. Svensson GL, Lundberg M, Östgaard HC, Wendt GK. High degree of kinesiophobia after lumbar disc herniation surgery: A cross-sectional study of 84 patients. Acta orthopaedica. 2011 Dec 1;82(6):732-6.
2 Lotzke H, Jakobsson M, Gutke A, Hagströmer M, Brisby H, Hägg O, Smeets R, Lundberg M. Patients with severe low back pain exhibit a low level of physical activity before lumbar fusion surgery: a cross-sectional study. BMC musculoskeletal disorders. 2018 Dec;19(1):1-9.
3 Quack V, Boecker M, Mueller CA, Mainz V, Geiger M, Heinemann AW, Betsch M, El Mansy Y. Psychological factors outmatched morphological markers in predicting limitations in activities of daily living and participation in patients with lumbar stenosis. BMC musculoskeletal disorders. 2019 Dec;20(1):1-9.
4 Nissen M, Ikäheimo TM, Huttunen J, Leinonen V, Jyrkkänen HK, von und zu Fraunberg M. Higher Preimplantation Opioid Doses Associated With Long‐Term Spinal Cord Stimulation Failure in 211 Patients With Failed Back Surgery Syndrome. Neuromodulation: Technology at the Neural Interface.
5 Rundell SD, Davenport TE. Patient Education Based on Principles of Cognitive Behavioral Therapy for a Patient With Persistent Low Back Pain: A Case Report. J. Orthop. Sports Phys. Ther. 2010;40(8):494–501. doi:10.2519/jospt.2010.3264
6 Archer KR, Devin CJ, Vanston SW, Cognitive-behavioral based physical therapy for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial. J. Pain. 2015 Oct 14. pii: S1526-5900(15)00906-2. doi: 10.1016/j.jpain.2015.09.013.
7 Deyo RA, Martin BI, Kreuter W, Jarvik JG, Angier H, Mirza SK . Revision surgery following operations for lumbar stenosis J Bone Joint Surg Am. 2011 Nov 2;93(21):1979-86.
8 Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (Phila. Pa 1976). 2007 Feb 1;32(3):382-7.
9 Röllinghoff M, Schlüter-Brust K, Groos D, et al. Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine. Orthopedic Reviews. 2010;2(1):e3. doi:10.4081/or.2010.e3.
10 Jung JM, Chung CK, Kim CH, Choi Y, Kim MJ, Yim D, Yang SH, Lee CH, Hwang SH, Kim DH, Yoon JH. The Long-Term Reoperation Rate Following Surgery for Lumbar Stenosis: A Nationwide Sample Cohort Study with a 10-Year Follow-Up. Spine. 2020 Apr 24. —2058