why back surgery fails
TRANSCRIPT
Surgical Decision Making
• Much more problematic than infections or technical errors
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In this example, the surgeon states ‘discogenic back pain’. By definition discogenic means it is caused from the disc. The patient may have back pain along with radicular (nerve) pain from nerve compression but it would not be discogenic low back pain it would simply be low back pain. Without a fundamental understanding of the problem, it is unlikely the physician will arrive at satisfactory solutions.
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Why back surgery fails
• 55 y/o woman with back pain without radiclopathy
• Spondylolisthesis• Obese• No improvement with PT, chiropractor, Pilates,
no relief with ESI’s
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MRI
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S1 transitional vertebrae, spontaneous reduction of spondylolisthesis while laying down for the MRI. Spondylolisthesis was evident on standing Xray.
With multiple degenerative discs, it is impossible to discern where the pain generator.
In this setting, unless the goal of surgery is to decompress a nerve and relieve sciatic pain (radiculopathy) there is no reasonable chance of back pain relief since any of the 5 degenerative discs could be causing the low back pain.
Unfortunately, the surgeon thought he knew better.
• Underwent L5-S1 minimally invasive decompression and fusion (TLIF)– ‘Minimally Invasive Specialist’– Leg pain post op…no leg pain pre-op– Worse low back pain post op– 10 months post op absolutely no better– Sent to ‘Pain Specialist’ for chronic pain and ‘failed
back’.
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Post Op MRI
Expected changes
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Post Op CT scan
Interbody spacer ‘cage’ (red rectangle) sitting in the canal
S1 pedicle screw in the canal
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Yellow defines the canal, the screws obviously intrude into the canal where the nerve roots are located
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So does the cage (red oval)
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• This patient was essentially abandoned by her surgeon with a diagnosis of ‘failed back syndrome’.
• The failure was in the surgical planning as well as the execution.
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Patient DL 84y/o male
Pt with metastatic renal cell cancer (kidney cancer)
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Patient followed up 1 year after surgery with severe back pain. He had loosening of the screws (halo images around the screws to the right).
The cancer is seen in L2 as well as L5 and S1 at the bottom. It is the white color inside the bone.
The patient had widespread metastasis. Why selectively choose one region to operate on?
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Normal appearing bone
White color is metastatic bone
White color is metastatic bone
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Surgeon didn’t understand the type of cancer involvedThis particular cancer was not osteolytic which means the bone was eroded. When the bone erodes, it gets weaker and instrumentation like this may help to support the spine.
Instead, this patient had osteoblastic metastasis which means that the bone is denser and will not collapse and thus does not need support with screws and rods.
Had the surgeon understood this, they would have potentially avoided a surgery which has served him no benefit and at the age of 84 years old, this type of surgery carries significant risks.
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1-9-13• SW• 55 y/o woman• Leg and back pain• Grade 1-2 spondy
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X-ray in prone position. Yellow arrow indicates challenging angle to access L5-S1 disc space.
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The red line indicates surgeon’s line of sight. Seeing the back of L5 is blocked in large part by S1. As a result, he chose an anterior fusion at L5-S1.
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In this Xray of the patient supine, the yellow arrow shows the angle in which the disc must be addressed anteriorly. Unfortunately, the surgeon didn’t recognize that the angle is so steep that the anterior bony pelvis was in the way.
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2-8-13The cage protrudes significantly into the abdomen and the curved fixation plate is not even in the anterior of the S1 body.
No reduction of L5 on S1 was not possible either. Since there is no significant contact between the bone graft and vertebral body endplates, the fusion possibilities are limited.
The pedicle screws in L5 are also not beyond the pedicle into the body and the angle was limited by the angle of L5 from the posterior approach.
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6-14-13
4 months laterLoose screwsLeg pain the same as preopBack pain worse
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8-20-13Revision by original surgeonAwkward position of screws
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9-20-131 month post op from revisionScrew failure of right L4 screw
Upper right screw on right image, the rod disengaged the screw
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• Revised• Interbody support• Reduction of spondylolisthesis• Rigid internal fixation• Leg and back pain resolved
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• Imperative that surgeon understands the anatomy, the etiology and physiology of the disease that they are treating.
• Thanks for your attention
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Which surgeon?
• Fellowship Trained• Board Certified• Experienced• Diligent about the literature• Second opinion• [email protected]
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Questions?
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