Declining the second spinal surgery

We long talk of the need for conservative treatments in problems of the spine. We also talk about why Prolotherapy and Platelet Rich Plasma therapy should be considered first before deciding on a complicated spinal surgery. But what about the patient who already had spinal surgery and did not see the results hoped for? Should they opt for the second surgery? Again, in our opinion, more conservative approaches should be explored first.

If one did their homework, they would see medical research like this:

“Older patients less likely to recieve spinal revision surgery.”
Was it because the surgeries were more successful in older patients? No, according to researchers “The likelihood of repeat surgery for spinal stenosis declined with increasing age and comorbidity, perhaps because of concern for greater risks.” So there were less surgeries because older patients were afraid of complication. (1)

“Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial.” (2)

“Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved.” (3)

Why did the surgery fail in the first place?
When I was in medical school, I did surgical research and assisted in the operating room more than my classmates. By the time I had finished medical school and internship (where I spent as much time as possible doing orthopedic procedures) I had seen too many surgical failures.

The most common cause of failed back syndrome is poor judgment on the part of the physician. Surgery prescribed as a last resort, with a hope and a prayer that it might alleviate the pain.

Unfortunately, often times surgery does little to help, and in fact can make things worse, as cited above. Frequently surgery results in post-operative scarring, which often exacerbates the initial problem or causes new pain syndromes.

Subsequent “corrective” surgery can help in some cases, particularly if the damage done by the first operation involves clearly observable physical complications like nerve root compression, massive scarring, bone spurring or foraminal compression.

Why Would Back Surgery Fail?
1. The surgery itself damaged previously undamaged ligaments and muscles.

2. Relieving nerve impingement may cause instability in the spine.

3. The surgery did not address the problems causing the initial pain.

4. Fusion of the vertebrae causes breakdown of the areas above and below the fusion.

5. Scar tissue may grow unto the nerves and cause nerve impingement.

I estimate that 95% of the people we see in our clinic have loose and damaged ligaments. This is why when a patient comes in, we examine them with our hands first and not with MRI. Touching the patient at various points on the back helps recreate their pain and allows us to address the exact spots causing it.

References
1. Revision surgery following operations for lumbar stenosis.Deyo RA, Martin BI, Kreuter W, Jarvik JG, Angier H, Mirza SK.Revision surgery following operations for lumbar stenosis.J Bone Joint Surg Am. 2011 Nov 2;93(21):1979-86.

2 . Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Spine (Phila Pa 1976). 2007 Feb 1;32(3):382-7.

3. Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine.
Orthop Rev (Pavia). 2010 Mar 20;2(1):e3. Röllinghoff M, Schlüter-Brust K, Groos D, Sobottke R, Michael JW, Eysel P, Delank KS.