Orthopaedic spine surgeon Ralph Rashbaum, MD continues his discussion about failed back surgery syndrome (FBSS). In this segment, Dr. Rashbaum explains his approach to proper patient care when back surgery is not successful.

SpineUniverse: When a patient comes to you and their surgery was not successful, what do you do?

Dr. Rashbaum:
We find out what went wrong. Typically, the patients I see that clearly have failed back surgery syndrome (FBSS) go back to their doctor, only to find that their doctors are totally disengaged in finding the truth. Unfortunately, this is common.

• I’m sorry, I’ve done everything I can; I did it the right way, – by implication they’re alleging they didn’t commit malpractice, and, frankly, most of them haven’t.
• I can’t help you, you’ll have to go someplace else, doesn’t help the situation. They don’t arrange for the “someplace else,” and basically what happens is these people become a referral base or repository in chronic pain syndrome in a pain doctor’s clinic.

One of the biggest concerns pertains to whether or not the patient is being subjected to a robust reassessment by the operating surgeon. I’d like to think that they were, but they’re not – at least not uniformly. They’re just sending these people down the road, where the problem could easily be assessed by repeating diagnostic studies like an MRI with gadolinium; an enhancer that helps us ferret out scar tissue from a recurrent disc herniation. You can’t get anywhere if you operate on somebody with scar tissue for leg pain, but you certainly can if they have a recurrent disc herniation.

SpineUniverse: Once you find out what went wrong, what are the next steps?

Dr. Rashbaum:
Sometimes we’ll do injection therapy to help us figure out where the pain is coming from. We need to determine if the pain now is mechanical facet joint pain, mechanical disc degeneration, or painful disc syndrome. Above all, we don’t give up on these patients. We do whatever is needed to reinvestigate, because the important issue with FBSS is that time is of the essence.

Pain is a signal that something is wrong. It’s like taking our hand off the hotplate. If we leave our hand on the hotplate too long, then that pain can go from being an acute signal to chronic indolent pain. Over time, it becomes a disease called Chronic Pain Syndrome Disease. The longer we live with pain that’s unabated, the more we suffer psychosocial, financial, and physical issues. We also lose conditioning.

So the message is, that if the patient doesn’t do well with the planned surgery, figure out what went wrong. Get your ego out of the way and say, okay, this is what happened, this is what I need to do. And that becomes the most important thing in trying to rectify the situation. The single most important thing for failed back surgery syndrome is to do the right surgery on the right patient at the right time, and execute it in the right way. Simple.

SpineUniverse: Do many of these patients need to undergo revision surgery?

Dr. Rashbaum:
What you’re asking is what percentage of FBSS patients could undergo a second surgery and recover with improvement. I hate to say this, but the number of those people that are likely to successfully recover from a second surgery, let alone a third, is not great. Every time you have a re-operation, the likelihood of success diminishes substantially, so by the time you get to the third and fourth surgery, you’re not doing very well. Patients who have failed to benefit from surgery and/or revision surgery and continue to have pain are often good candidates for neuromodulation–spinal cord stimulation.

SpineUniverse: What does the data show regarding the success rate of spinal cord stimulation?

Dr. Rashbaum:
Studies both in Canada and in the United States indicate that the satisfaction and benefit rate of patients with FBSS initially implanted with a spinal cord stimulator were statistically better than patients who underwent revision surgery. Clearly, there are certain surgeries that can’t be revised with the expectation of having good results. With spinal cord stimulation, we have an alternative. Physicians from the family practitioner on up to the sophisticated spine surgeon need to recognize that surgery is not he be-all and end-all. In surgeon training, one of the mantras we’re taught, which now sounds like nonsense, is A chance to cut is a chance to cure. It’s simply not true anymore.