After you have spine surgery, you’ll never have pain in that site again, right?
Unfortunately, that isn’t always the case. Whether it’s minutes after surgery or years later, when you feel pain or other symptoms in the same place you had spine surgery, you may wonder whether your procedure wasn’t fully successful.
SpineUniverse reached out to neurosurgeons James S. Harrop, MD, FACS and John L. Gillick, MD to help clarify some of the complexities of pain after spine surgery.
Drs. Harrop and Gillick: Unfortunately, spine surgery and pain symptoms are quite complicated. So, it is not uncommon for patients to have similar pain after surgery, but that does not mean your surgery was not successful.
The first questions we ask when we see a patient with persistent pain after surgery are what were the goals of surgery, and were they addressed with the primary operation? For example, patients with peripheral neuropathies, such as diabetic neuropathy may have painful neuropathic pain as the cause of their symptoms. These symptoms are classically described as a burning type of pain and are typically due to intrinsic nerve problems and not external compression.
Even a patient with severe spinal stenosis who undergoes a surgical decompression will not get relief from this type pain after surgery, since this is due to an intrinsic problem with the nerve, not the compression. Therefore, understanding what the goal of the surgery is and what pain relief will you get from the surgery is important. Also, most spinal surgery does not specifically improve back pain, and it can often intensify it for a period of time. Make sure you discuss the symptoms you have and their expected relief from surgery.
There is also the question whether this surgery was to address compression of the spinal cord or to relieve pain. Spinal cord compression does not cause pain; so, surgery to help pain in a patient with only spinal cord compression may not alleviate the pain symptoms. Often, there can be a misunderstanding between the patient’s goals and the spine surgeon’s goals. Therefore, it is important to review the specific goals and aims of the surgery with your surgeon before surgery.
If immediately after the completion of surgery, the patient awakes with a similar type of pain, there may be concern that the nerve may not be completely decompressed. However, it is very common for patients within the first 6 weeks to have episodes of similar pain to what they experienced before surgery. This prolonged pain seems to be more persistent and noticeable the longer the patient had symptoms prior to surgery. The return of pain may also correlate with increased activity due to stretching of the previously traumatized nerve. Therefore, if a patient has an episode of similar post-operative pain (typically less than pre-op) within 6 weeks of surgery, he or she should not get too concerned unless it becomes persistent or progressively worsens.
Another possibility is that the patient re-herniates more disc material. The spine is a mobile system, and surgery for a disc herniation in the lumbar spine usually removes or shaves only a small portion of the total disc (<10%). Thus, we know there is a 3-6% risk of a recurrent disc problem happening after lumbar discectomy surgeries. Unfortunately, even with a well-done surgery, the patient may develop similar symptoms due to inherent problems with his or her spine.
Longer-term problems can occur after spine surgery. Unfortunately, if the patient has surgery, they have differentiated themselves from the general population and have a higher risk of having another spine problem, and thus, are at a higher risk for a second spine surgery. For example, there is a 2.9% annual risk of having adjacent level disease above or below a cervical fusion after an anterior cervical fusion.
Overall, the best way to understand whether a patient’s new pain is related to a former surgery is to revisit the goals of the original surgery and use imaging scans as clinically warranted in order to identify the underlying cause of the new pain to determine if a connection exists.
Q: If the spine surgery was successful, what are some reasons the patient could experience pain in the surgery location?
Drs. Harrop and Gillick: Many of the answers to this question are listed above, but another common pain symptom patients experience after lumbar decompression is pain over the side of their thigh by the hip. On physical examination, they have tenderness and pain over this area (trochanteric bursa). This pain is often caused because the patient was hunched forward before the surgery, and this results in the patient developing a shorter muscle along their thigh. After surgery, the patient does not have nerve compression, and can lean back to their normal posture and able to stand upright. The upright standing causes this previously shortened muscle to now be stretched and inflamed. Fortunately, this often improves on its own. If it doesn’t improve, the patient may get relief with an injection into this region.
Another example discussed above is patients with severe radiculopathy who get “reminder pain” after spine surgery. Again, this typically is alleviated with time. But, if the pain becomes intense, sometimes the patient may get a short course of steroids to "calm" the nerve. This would be done after the spine surgeon has ruled out an infection as the cause of the pain.
Q: If a patient has pain in the same site as a previous spine surgery, what should he/she do? Call his/her primary care physician? The previous spine surgeon?
Drs. Harrop and Gillick: Patients should have office visits with their spine surgeon or team to review their progress. Thus, if a patient has new or persistent pain after surgery, the patient should first speak to their spine surgical team. Depending on the symptoms and their severity, there are multiple options. Many of the problems patients have after surgery are related to the spine adapting to its new position. Thus, it’s important to review the post-operative symptoms with the surgery team to determine if that’s the case or if something different is at play.
If pain is persistent, then high-definition imaging (MRI or CT) may be used to define the etiology of the pain. The patient should go back to his or her surgery team to review these concerns. However, if the patient feels that answers are not being fully explained, the patient should feel comfortable seeking a second opinion from a different spine team.