Failed back syndrome

[5] Patients may also experience pain at a different level from the location originally treated, along with an inability to fully recuperate and restricted mobility.

[13] A similarly designed study by Mardjekto et al. found that a concomitant spinal arthrodesis (fusion) had a greater success rate.

)[citation needed] Another highly relevant consideration is the increasing recognition of the importance of "chemical radiculitis" in the generation of back pain.

[24] A primary focus of surgery is to remove "pressure" or reduce mechanical compression on a neural element: either the spinal cord, or a nerve root.

A 2005 review by Cohen concluded, 'The SI joint is a real yet underappreciated pain generator in an estimated 15% to 25% of patients with axial LBP'.

[34] Studies by Ha, et al., show that the incidence of SI joint degeneration in post-lumbar fusion surgery is 75% at 5 years post-surgery, based on imaging.

[35] Studies by DePalma and Liliang, et al., demonstrate that 40–61% of post-lumbar fusion patients were symptomatic for SI joint dysfunction based on diagnostic blocks.

[52] In a study from Denmark reviewing many reports in the literature, it was concluded that smoking should be considered a weak risk indicator and not a cause of low back pain.

Computerized tomography in conjunction with metrizamide myelography in the late 1960s and 1970s allowed direct observation of the mechanisms involved in post operative failures.

[11][66][69][70][71] Even though the complications of laminectomy for disc herniation can be significant, a recent series of studies involving thousands of patients published under auspices of Dartmouth Medical School concluded at four-year follow-up that those who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status.

However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment.

Patients' perception of improvement had a much stronger correlation with long-term surgical outcome than structural findings seen on post-operation magnetic resonance imaging.

The clinician must be cautious when reconciling clinical symptoms and signs with postoperative computed tomography findings in patients operated on for lumbar spinal stenosis.

Initially there was a high incidence of success, but recurrence of neurological involvement and persistence of low-back pain led to an increasing number of failures.

[103][104][105][106][107][108] Antimicrobial prophylaxis reduces the rate of surgical site infection in lumbar spine surgery, but a great deal of variation exists regarding its use.

Based on the CDC guideline, a single dose of prophylactic antibiotic was proven to be efficacious for the prevention of infection in lumbar spine surgeries.

Neoplasia also includes direct seeding of the cerebrospinal fluid (CSF) from primary central nervous system (CNS) tumors such as glioblastoma multiforme, medulloblastoma, ependymoma, and choroid plexus carcinoma.

In theory, all failed back patients have some sort of nerve injury or damage which leads to a persistence of symptoms after a reasonable healing time.

Some patients are simply unfortunate, and fall into the category of "chronic pain" despite their desire to recover and the best efforts of the physicians involved in their care.

[140][141][142][143][144][145][146][147][148][149][150] Even less invasive forms of surgery are not uniformly successful; approximately 30,000-40,000 laminectomy patients obtain either no relief of symptomatology or a recurrence of symptoms.

[188] In a groundbreaking Canadian study, Waddell et al. reported on the value of repeat surgery and the return to work in worker's compensation cases.

[196] In a related Finnish study, a total of 439 patients operated on for lumbar spinal stenosis during the period 1974–1987 was re-examined and evaluated for working and functional capacity approximately 4 years after the decompressive surgery.

[198] In a comprehensive set of studies carried out by the University of Washington School of Medicine, it was determined that the outcome of lumbar fusion performed on injured workers was worse than reported in most published case series.

[200][201][202][203] The identification of tumor necrosis factor-alpha as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with FBS.

[204][205][206] Targeted anatomic administration of one of these anti-TNF agents, etanercept, a patented treatment method,[207] has been suggested in published pilot studies to be effective for treating selected patients with chronic disc-related pain and FBS.

[210][211] In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation, thereby enabling more accurate localization of the pain generators responsible for symptom production.

[212] Although this technique began more than a decade ago for FBS, the efficacy of epidural steroid injections is now generally thought to be limited to short term pain relief in selected patients only.

The influence of financial forces in the development of new technologies and its immediate application to spine surgery shows the relationship between the published results and the industry support.

The scientific literature doesn't show clear evidence in the cost-benefit studies of most instrumented surgical interventions of the spine compared with the conservative treatments.

We still are in need of randomized studies to compare the surgical results with the natural history of the disease, the placebo effect, or conservative treatment.