Spinal Revision Surgery: How Correct Indication Makes the Difference (Part 2 of 3)

This is part two of a three-part series on spine surgeons discussing spinal revision surgery and efforts to avoid failed back surgery syndrome. Neel Anand, MD, is the director of spine trauma at Cedars-Sinai Spine Center in Los Angeles, where he also serves as a clinical professor of surgery. In the past, he served as the director of orthopedic spine surgery and director of spine fellowship at Cedars-Sinai. Dr. Anand has dedicated his more than 20 years of practice to minimally invasive approaches for treatment of spinal disorders in adolescents and adults.

Here Dr. Anand discusses how crucial a correct indication can be in treating failed surgeries and preventing them from occurring in the first place.

Question: What causes spinal surgery to fail?

Dr. Neel Anand: When we look at the causes of failed back surgery, the biggest is the indication, the very fact the surgery was done, and why was it done. Many a time, the particular surgery should not have been done with the particular problem or the patient didn't need surgery in the first place. It could be for a number of reasons that the surgery didn't work — it wasn't done the right way, there was a later complication or the fusion did not occur. Overall, it always narrows down to the indication for the primary surgery. The next aspects to consider are technique and execution, though I do believe technique, the way the surgery was done, is not that important in creating failed back surgery. Most surgeons do a good job.

Sometimes the problem can come out of a failure to recognize the complication. Maybe everything was done great, but something went wrong, and it wasn't corrected right away. Maybe the patient could've been treated conservatively. Maybe they had a couple of disc herniations, but only one was symptomatic instead of the five-level fusion they received. Maybe the patient just needed a decompression but instead got a three-level fusion. If you perform a fusion procedure for someone who has generalized back pain, they don't do very well. But for someone with the true pathology, it is an excellent procedure; it's fantastic for the right patient and indication. Fusion has gotten a bad name because it's been done for the wrong indication. We do good fusions 80 to 90 percent of the time, if done properly.

Q: When someone comes in needing revision surgery, what is the first thing you must do?

NA: To me, the biggest thing is patient history, to delve deeply into why the patient had the original operation in the first place. What were the patient's symptoms before the surgery and did they ever get better? Usually, a patient never got better from the surgery he or she had because either the indication or the procedure done was wrong. I would go back and try to get studies from before the first surgery to see where the real problem was and assess why it didn't get better.

One subset of patients say they never have gotten any relief, and another subset say they did well, but a year or so went by and they started having problems again. The latter group usually has a failed fusion. They may have also had other problems that were not recognized before and now become symptomatic. Perhaps the alignment was off and at first it felt great but progressively it got worse as time went on.

Once you have assessed what happened in the first operation, then you can do an MRI or CT or EMG nerve conduction test. But, really, history is a huge clue. If someone never got better, you have a red flag staring at you. Was that the right surgery the patient should've had? Are they psychosocial issues that need to be addressed? There are so many facets that fall into place if a patient never got better or had a complication. Try to find out; maybe get the operative notes and really get to know the patient and their problems.

Q: How do you properly select patients?

NA: Again, patient selection goes back to history and what the patient is telling you. Spend some time hearing their story, and a number of things matter. If it's back pain, where is it? Many times buttock pain comes from stenosis and is not the same as axial back pain. For leg pain, try to map the nerve it follows. If you have pain radiating down the calf into the toe, it's probably is affecting the L5 nerve. If imaging studies such as an MRI shows L2 or L3 discs as being problematic, it does not explain pain going down the L5 nerve. History is critical in analyzing. For instance, stenosis hurts when you stand and walk but gets better from sitting. What if they stand and are still hurting and when they lean forward it doesn't get better? When you lean and feel better, it's neurological stenosis. If you lean forward and it's not getting better, maybe it's a vascular insufficiency.

Get all the pieces together, and they have to fit. Be a detective. Ninety-five percent of the diagnosis can be done from talking and listening to the patient and doing a detailed physical exam.

Q: Is technology helping to reduce spine surgery failures?

NA: Technology can help many things and make what we do a little better, but no, it has not improved failed spinal surgeries when they come from an indication problem. It may help with the execution and making the surgery easier or more accurate, but it does not prevent true failed spinal surgeries.

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