Causes of Failed Back Surgery Are Multifactorial
– Ralph F. Rashbaum, MD
SpineUniverse: How can surgeons reduce the risk for failed back surgery syndrome (FBSS)?
We start by identifying "all" the pathologic processes that exist in the patient at the time he/she presents. A patient may have a herniated disc as the major contributor to the problem of pain down the leg, but he/she may also have a bony impingement on the nerve, either at that level or above or below the nerve running from the spine into the leg. If you fail to address all the areas of compression at the first surgery, you are going to create a FBSS and the patient isn’t going to improve.
So, in addition to not making the right patient selection, we have a failure to make the right diagnosis, which leads to failure to do the right surgery. If, in the process of diagnosing a patients’ pain problem, we come to the conclusion that we have to decompress the nerve, we have to be absolutely sure of the treatment path we develop. If the decompression is extraordinarily large, to the extent that ambulation and physical activity brings on an iatrogenic fracture, then we’ve created a problem. It’s a double-whammy. The wrong surgery combined with the wrong rehabilitation can cause FBSS.
SpineUniverse: Much has been written about the connection between obesity and back problems. What are your thoughts on this?
One of the biggest problems we deal with as a society is obesity. This is a huge problem. Studies show that there’s not a higher incidence of herniated discs in the obese population versus the normal-weight population. But what happens is that the obese population is so deconditioned that their rehabilitation process is prolonged and they tend not to do well. So when possible, surgeons need to encourage obese patients to diet and make them participate in their own well-being.
Some patients who are overweight become obese. These are people who, although not morbidly obese–which by definition is 100 pounds over ideal body weight – are between 30-100 lbs overweight. The term “morbid obesity” indicates that other body systems suffer as a result of the excess weight (ie, the pancreas, heart, lungs, peripheral joints, hips, knees, ankles, and the spine). Beyond that, we see super-morbid obesity–150 lbs over normal body weight.
So what does this mean in terms of the back and healing? You may have done a masterful surgery for the problem of leg pain, but inherent in that surgery is the creation of potential for having back pain and FBSS. This is why it’s so important to pick and choose our patients wisely.
SpineUniverse: So it appears that you take a holistic approach to surgery and avoidance of FBSS. Would that be an accurate statement?
As surgeons, we need to understand why we’re doing a procedure and take all factors that could contribute to a bad outcome into account. There’s no question in my mind that we are creating FBSS more and more as we treat back pain without regard to lifestyle and other factors that create the problem in the first place.
We have more spinal surgeons seeing more people with back pain, which for the most part, is a benign situation, and subjecting these people to ill-conceived surgery. My concern as a spine surgeon and a pain specialist is that I’m seeing much more unnecessary spine surgery and very little treatment of lifestyle factors that, were they addressed, might negate the need for surgery.