SpineUniverse spoke with Dr. Ralph Rashbaum, an orthopaedic spine surgeon at the Texas Back Institute. Here, Dr. Rashbaum discusses failed back surgery—how it’s defined, when it may develop, and other important factors.
Failed back surgery syndrome (FBSS), whether it occurs in the neck or lower back, takes into account the immediacy of the failure. Let me explain. If a patient comes in with a herniated disc, and the disc is taken out and they have a complete recovery, that’s considered a successful surgery. If, however, later on down the road, the patient develops mechanical lower back pain, they get thrown into the same bailiwick, if you will, of failed back surgery. This is a common mistake and simply not the case. In order to be classified as failed back surgery syndrome, there has to be a correlation between the surgical event and the failure to improve as a direct result of the surgery. This is an important distinction. Symptomatology that occurs months or years later as a result of aging or factors unrelated to surgery cannot be classified as FBSS.
SpineUniverse: When does FBSS first show up?
Getting back to my example about a herniated disc. When you remove the disc, you’re doing it to alleviate leg pain. If the patient ends up getting back pain, I wouldn’t call that FBSS. The back pain is a sequelae of the initial surgery, brought on by the process of aging. Not everyone who has surgery for herniated disc will develop back pain afterward. Many surgeons agree that FBSS is time-dependent. I took the patient to the operating room and the surgery didn’t work. When patients don’t improve within the first 30 or 60 days following surgery, that’s when you start to consider FBSS.
SpineUniverse: Determining a true FBSS seems complicated. Would you agree?
Unfortunately, the term failed back surgery syndrome has been relegated to a big wastebasket where those patients that don’t benefit from surgery initially and those patients who initially did benefit, are lumped together. During my fellowship with Dr. Richard Rothman, he considered a failed back surgery to occur within the first 12 months after the initial surgery; he simply put a time-dependent stamp on it. I’m not certain that I can do that.
If somebody has surgery tomorrow, and three years from now they have a problem, it could be related to the surgery because they wind up with degenerative changes and back pain. But for all intents and purposes, FBSS is an almost universally abused consideration. I tend to consider FBSS only in cases where patients have surgery and, in the initial period following surgery, it’s obvious that the intent of the surgery didn’t work.
SpineUniverse: What are some of the factors influencing the development of FBSS?
In describing this syndrome, we have to consider patient selection. In other words, you increase the risk for failed back surgery syndrome by operating on the wrong patient. For example, patients with significant psychosocial issues are not going to be improved by an interventional surgery. It becomes imperative to figure out if we’re treating the pain in their brain or are we treating a structural component of their spine that’s causing them to perceive pain in their brain? It’s a subtle distinction, but an important one.
One of the things we’ve seen over and over again is the failure to achieve the same level of response to a surgery if the patient comes from a workers’ compensation classification or some type of legal issue. Whether it’s a motor vehicle accident or injury on the job, anything that causes them to be litigious seems to preclude to a bad result. These factors are important to evaluate. And the only reason to operate in patients that present with these circumstances is if they’re having progressive neurological decompensation. Most of what we do in spine surgery is elective and based on “my back hurts, doctor.” That’s not going to kill or paralyze anyone. So to operate on less than bona fide and qualified patients will compromise the result.