Failed back surgery syndrome is a generic term used to describe persistent or new pain after spinal surgery. The typical scenario is one in which the patient has had one or multiple spinal surgeries, and they are in fact no better, or worse, compared to before they had any surgery. Failed back surgery patients are a challenge to the spine surgeon. These patients often get the “I don’t know why you didn’t get better, go see pain management” response from surgeons. However, in my opinion, these are some of the most appreciative patients if the surgeon takes the time to figure out what’s wrong and devise a surgical or nonsurgical plan that can alleviate their pain.
Generally, patients who develop failed back surgery syndrome are divided into two categories. The first group are patients who never got better, or got worse, immediately after surgery. When a surgeon is faced with a patient who did not improve after the surgery, that physician has to ask the question of whether the wrong surgery was performed for the patient’s problem. For example, the patient’s buttock and lower extremity pain is coming from peripheral vascular disease causing poor circulation, but the surgeon performed a lumbar spine surgeon. In that scenario, the patient would obviously not improve from the spinal surgery. Unfortunately, this is not an uncommon scenario. It highlights the importance of spending time with the patient to obtain a thorough history and perform a good physical exam in order to come to the correct diagnosis. Another explanation for why the patient did not improve after spinal surgery is that the surgeon failed to achieve the desired surgical goals. For example, this can happen if the surgeon inadvertently left behind pieces of bulging disc or bony spurs, resulting in an incomplete decompression of the pinched nerve(s). It is also possible that the surgeon operated on the wrong level of the spine! When the surgeon is faced with a patient who not only didn’t improve but also felt worse immediately after surgery, there are several reasons. One possible explanation is technical errors during the surgery that caused damage to previously normal structures. This can occur in spinal fusion surgeries if the hardware are inserted imperfectly and cause trauma to the nearby nerve roots or facet joints.
The second group of patients are those who got better initially after their spinal surgery, but then the pain came back. One of the causes a surgeon must think about is an infection. A postoperative infection can take several days to weeks to declare itself, and should be suspected in someone with worsening pain at the surgical site. Another cause is a recurrent disc herniation or scar formation causing pinching of the nerves. In the case of a patient who had a successful fusion procedure (ie significant or complete relief of their preoperative symptoms) but now have return of pain, the surgeon should consider the possibility that the fusion did not heal and the hardware may have become loose.
There is a unique group of patients who also fall into the failed back surgery category. These are patients who had fusion surgery, but for one reason or another, their back was fused in a straight or flat alignment instead of the normal curved alignment. When the patient is fused flat or straight, their posture becomes pitched forward. In order to compensate for this pitched forward alignment, patients to have exert a tremendous amount of energy to activate their back, buttock, and leg muscles in order to bring themselves to a more upright posture. Overtime, this results in muscle fatigue and back, buttock, and leg pain.
A spine surgeon can employ a multitude of diagnostic modalities to determine the cause of your failed back surgery syndrome, including blood work, xrays and advanced imaging such as CT scan and MRI, and nerve conduction studies. It is important to discuss with your physician which diagnostic tools and treatment options are best for you.
ABOUT DR. NGUYEN
Lam Nguyen, MD – Orthopedic Surgeon, Spine Surgery Dr. Lam Nguyen is a fellowship-trained orthopaedic surgeon who specializes in spinal surgery. Following his undergraduate studies at Duke University, where he majored in psychology, he attended medical school at the University of North Carolina School of Medicine at Chapel Hill. He was inducted into his medical school’s John B. Graham Research Society. Dr. Nguyen subsequently completed his Orthopaedic Surgery Residency at Loyola University Medical Center in Chicago, Illinois. During his residency, Dr. Nguyen investigated the effect of cervical spine alignment on spinal posture and biomechanics. The results of his research have been published in peer-reviewed orthopaedic journals and presented at multiple national and international scientific meetings. Dr. Nguyen was also awarded the distinguished title of “Chief Orthopaedic Resident” during his last year of training.
After his residency training, Dr. Nguyen pursued a one-year fellowship in spinal surgery, where he trained with nationally and internationally renowned spine surgeons at Oregon Health and Science University in Portland, Oregon. Dr. Nguyen specializes in the comprehensive care of spinal disorder, from the cervical spine (neck) to the sacrum (tailbone). This includes degenerative conditions (disc herniation and stenosis), as well as spinal deformities (scoliosis and kyphosis), spinal trauma and instability, spinal infections, and metastatic spinal tumors. Dr. Nguyen also has experience in minimally invasive spinal decompression and fusion, cervical disc replacement, and complex revision surgery. The diagnosis and treatment of spinal conditions is a complex process, and Dr. Nguyen relies on a thorough assessment to recommend the right surgery for the right patient. In an era when medical decision is largely based on laboratory results and imaging findings, Dr. Nguyen still believes in the art of medicine: correlating patient symptoms with objective study results and offering the appropriate treatment solutions. He understands the stress and challenges facing the possibility of surgery and aims to help patients achieve a peace of mind in understanding their problem. He takes pride in listening to patients, and helping them formulate an individualized plan that is based on high quality science and cutting edge technology. Dr. Nguyen finds satisfaction in guiding patients through surgery toward their fullest potential recovery.
Dr. Nguyen is a published scholar, having authored a dozen peer-reviewed articles and multiple book chapters since 2006. He is a member of several spine surgery societies, including the North American Spine Society, the International Society for the Advancement of Spine Surgery, and AO Spine North America.
In his free time, Dr. Nguyen enjoys spending time with his wife who is a child and adolescent psychiatrist, traveling, and cooking.
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