Scott Webb (Host): On today's podcast, we're discussing failed back surgery syndrome, you know, persisting or recurring back pain after back surgery, with Dr. Oren Blam. He's an orthopedic surgeon and spine specialist. And I'm also joined by Dr. Michael DeMarco. He specializes in physical medicine and rehabilitation, electrodiagnostic medicine, and interventional spine care.

 Welcome to A Bone to Fix from Orthopedic Associates of Central Maryland Division. I'm Scott Webb, and I've got A Bone to Fix with you. It's nice to have you both here today. We're going to talk about back problems, and especially back pain after back surgery. I have a bad back, but I've never had back surgery, but lots of folks have this persisting, recurring back pain after surgery. So Dr. Blam, I'm going to start with you. Like, what exactly is failed back surgery syndrome? That sounds very ominous. And how is it defined clinically?

Dr. Oren Blam: Thanks, Scott. And the term failed back surgery syndrome is one that's very emotional. Someone goes into a back surgery just like any medical treatment with a lot of hope and expectation that their problem's going to be fixed and that they'll be good now and forever. And that is, of course, the goal for any back surgery or any medical treatment. And when someone has persisting or recurring back pain, either early on after surgery or years after surgery, it can be very disappointing in addition to being really painful.

The bottom line is, if you've had back surgery and your problem isn't better, or if it comes back again in the future, you're upset and you want to feel better. And there are many different causes. It requires really a careful medical evaluation. We talk to the patient. We listen to the patient. That's probably the first thing to do. And we try to figure out why. Why did the surgery not help as we had planned? Or why did the pain come back? Is there a new back problem, or is it the same problem that wasn't fixed adequately? Is there a complication? So, a careful medical evaluation. It involves talking and communicating with the patient. It involves a physical exam, neurologically and otherwise. It involves imaging studies or other testing. We try to get at the root of the problem in order to come up with the best solution.

Host: Sure. Yeah. And Dr. DeMarco, let's talk about, like, what are some of the most common reasons that a patient may continue to experience pain after back surgery? It sounds like it could be sort of a litany of things, and figuring it all out is obviously the responsibility of the experts. But what are some of the common reasons?

Dr. Michael DeMarco: I divide these patients into about four groups. And the first one would be very unfortunate in a patient that maybe didn't need surgery to begin with or simply that expectations weren't met. This is usually a patient with just simply pain some conservative treatments, and it doesn't help enough. And they have surgery, and it doesn't give enough relief of their back pain. The underlying issue is that even normal people can have abnormal discs on MRI, discs that are bulging or discs that show degeneration, and the decision to operate might be too quick and expectations are not met.

The second group is people who have severe pinched nerve and maybe wait too long to get the surgery done. These are people usually with a severe herniated disc, a lot of pain down the leg, constant numbness and weakness, and all that nerve damage has already occurred. And by the time they have surgery, they just have persistent nerve deficits that may not recover with time.

The third group is a patient who has persistent abnormalities, or I would say maybe not enough surgery was done. There are many patients, especially as they get older, that might have problems at all lumbar levels, and the surgeon, in an effort to be conservative and not cause instability or do too much, maybe they operate on the worst couple discs, but the remaining discs then are continuing to cause problems. And that kind of intersects with the fourth group, which is a group that has new problems. They have a clear-cut herniated disc, they have surgery, and they're just still having pain, and you do updated imaging. And boom, the next disc above kind of pops out and herniates. So, we have to be vigilant for the patient that has new problems.

Host: Right. Yeah, and Dr. Blam, you mentioned earlier how the importance of listening to patients, because I want to get a sense from you, like, how do you differentiate between let's call it normal post-surgical recovery pain and the true failed back surgery syndrome? And I'm sure listening to patients is a big part of that, imaging and so forth, but how do you tell the difference?

Dr. Oren Blam: Well, sometimes it's difficult, but it's always important as a physician to start with listening to the patient. Patients, if you give them enough time to describe what they're feeling, they'll get their symptoms out. Of course, having pain right after surgery sometimes is expected. But when things seem out of proportion, more severe than what we normally see, we have to look into it more.

One important thing to differentiate is, is someone having a persisting set of symptoms that they had before surgery that just didn't get better, or is it something completely new? And again, a patient can tell us that if we listen to them and ask the right questions. There are certain surgeries. There are known complications that we need to—if someone has new symptoms of pain shooting down the leg, fevers, chills, if the wound doesn't look like it's healing well, if there's drainage that we don't expect. You know, there are different things to look for to make sure there are no complications.

And in addition to the clinic history and physical exam, we may want to get X-rays, including X-rays when a person bends forwards and backwards to look for spinal stability. We might want to get advanced imaging studies like MRIs or CAT scans to take a closer look at the anatomy.

If implants were placed, were they placed correctly or not? Like Dr. DeMarco said a moment ago, was the surgery done in the right place, or was it done in enough places? So, imaging studies may be necessary to help that out. But it all starts with the careful physical exam and history, the listening to the patient and communicating clearly.

Host: Right. Dr. DeMarco, obviously, I'm sure you agree that listening is important, but I want to get a sense from you, dig a little deeper in terms of imaging and diagnostics and the role they play in really identifying the root cause. Like, the patient will say, "This is what's happening. This is what I'm feeling." But it sounds to me like the imaging part of it is really key for these persistent problems.

Dr. Michael DeMarco: Very much. Dr. Blam mentioned dynamic X-rays, looking at when the patient bends forward, bends backward, sometimes bending to the side, that can reveal some instability. But X-rays only show the bones and their alignment, and we have some additional tests. One would be MRI. That gives the most detailed view of non-bone structures, including the discs and if a nerve is being pinched. The MRI can be obscured if the surgeon places hardware, such as a lumbar fusion. There's a lot of artifact. And so, CAT scan or CT scan can be very helpful in those cases to look around that type of hardware. And then, very rarely, there's something called a myelogram where a radiologist would inject dye into your spine and then do a CT scan on top of it.

Those are imaging tests, but there is also a test of nerve function called an EMG and nerve conduction test. It's an electrical test looking at the health of the nerves, specifically looking for nerve damage. It also looks at other non-spinal causes of numbness and weakness, such as a pinched nerve in the hip, leg, or patients with nerve disease or neuropathy.

Host: So then, Doctor, are there some, like, effective non-surgical treatment options? You know, before heading back to the OR, there's some things that we can do, I don't know, physical therapy, injections, whatever it might be ways to manage this failed back surgery syndrome before we start talking, you know, surgery revision, if you will.

Dr. Michael DeMarco: Yes, there are. It's a fine line. Sometimes there is expected postoperative pain that the patient's having. There's also patients that are having a slower than average recovery. One thing is managing the patient's expectations. You know, what's normal, what's maybe just slower than average. Getting the patient involved in a mobility and exercise program would be the most important step, making sure they're doing that functional restoration. Doing it as a home program, but also doing it formally with a physical therapist. Patients do better with supervision. The physical therapist can also do things to the patient to reduce pain and inflammation and improve function.

We also use medications. It's similar to treating high blood pressure, where we might use multiple medications in small dosages to attack different sources of pain, different treatable targets for pain. We can do some injections into the spine. Some of the injections are steroid-based, and these are typically done under live X-ray. And there are some injections that are ablation of small nerve endings that can give some longer-term relief of pain in that area.

Host: So Dr. Blam, let's talk surgery revision if that's a thing, right? Like when, if ever, do you consider revision surgery? When is it appropriate? What factors influence that? Take us through the thought process from your perspective.

Dr. Oren Blam: As Dr. DeMarco was saying, we want to try almost always non-operative care for most problems. The only exception would be someone who may, God forbid, have a deep infection, progressive neurological deficits where the nerves aren't working and the weakness is getting worse. Those might be reasons for more urgent surgical treatment, but we try non-operative care first.

Having said that, if someone has long-standing back or leg pain after having had back surgery, surgery can sometimes be necessary, and it depends on what the underlying problem is. If there's a new level, if someone had surgery, for argument's sake, at L4-5, now maybe they have a new disc herniation or some cause of nerve pinching at L3-4, sometimes we need to do a surgery to unpinch the nerves. Sometimes there's instability where the spine becomes loosey-goosey. We see that a little bit on physical exam, but more on imaging. Sometimes that might require extending a fusion. Sometimes the problem might be that the hardware placed from a prior spinal fusion may be malpositioned. If a screw is not well-positioned, and if the screw itself is pinching a nerve, then we may need to take the hardware out and possibly replace it.

Sometimes people develop what's called deformity. That is the spine may not be shaped well either because they started off with that and it wasn't fixed adequately with the first surgery, or maybe the person developed worsening spinal shape or spinal deformity after surgery, and sometimes we need to correct that deformity. People have heard about scoliosis, when the spine might not be balanced from a frontal view. The head and trunk might be shifted to the left or the right. That sometimes needs to be corrected surgically. There's something else called flatback syndrome, where someone's spine might be fused, and they may have fixed the initial problem with a fusion, but perhaps the initial fusion fixed them with a forward flexed posture, where the person is leaning forwards, and they're structurally stuck that way. And if that's the case, one can do surgery to try to realign the spine and fix them so they're more erect. So, it depends on the specific problem that might be causing the pain, but there are different surgical ways to fix it.

And then, there is something else called neuromodulation. If someone has had a pinched nerve for a long time, they get a surgery that unpinches the nerve, and yet unfortunately, if the person developed nerve damage pain, the nerve's not pinched anymore, the surgery was successful in unpinching the nerve, but not successful in alleviating the pain because there's nerve damage, there are procedures to try to affect how the nerves themselves are sending pain signals to the brain, things called spinal cord stimulators or other kinds of peripheral nerve stimulators to try to alter the way the nerves conduct electricity and reduce the sensation of pain. So, there are different surgical procedures depending on what the actual problem is.

Host: Sure. And I'm assuming loosey-goosey is a clinical term?

Dr. Oren Blam: I think I may have created that. I'm proud of that one.

Host: Yeah, and somehow I knew exactly what you meant. You're a little loosey-goosey there. I understand completely. Dr. Blam, staying with you. And this has been good stuff today, really educational. Are there some emerging treatments or technologies that are really showing promise in improving outcomes for patients that are suffering from the dreaded failed back surgery syndrome?

Dr. Oren Blam: Well, I mentioned neuromodulation. There are newer types of spinal cord stimulators or peripheral nerve stimulators for people who have essentially nerve damage to try to reverse or alter the way nerves conduct electricity, and that's sort of a new technology emerging for different parts of the spine.

There are less invasive techniques that have been developed over the past 10, 15 years, which in the spine world is still relatively new, but less invasive ways to try to reach the spine if there's perhaps one nerve that might be pinched rather than multiple nerves. There might be smaller incisions or techniques to try to correct that without making big incisions. Sometimes a bigger surgery is better than a smaller surgery actually, if it fixes the problem safely. But sometimes a smaller surgery is better than a bigger one. It all depends, again, on the specifics. It gets complicated, but we try to really carefully look at all the imaging studies and then clearly communicate with the patient to let them know the options.

Host: Dr. DeMarco, going to give last word to you when we think about folks who have had or suffering from failed back surgery syndrome. We want them to speak up, you know, get the help that they need, your role in all this, final thoughts, takeaways?

Dr. Michael DeMarco: I want people to know that options exist. It's unfortunately common for people to have residual problems after surgery. Hopefully, they've been counseled properly that they could have some residual pain. But with these emerging technologies that we've discussed, and modern practices, we should really be able to minimize that. Nobody should continue suffering. Come in, be evaluated. We have plenty of tests, plenty of treatments to offer. Get additional opinions from other people. Different doctors may have slightly different approaches. So even if you've been to somebody and you're not happy with how things have turned out, come in and get another opinion. We always have options.

Host: Yeah. Well, I appreciate both of you being here, your time, your expertise. As I said, this is really educational. Thanks so much

Dr. Oren Blam: Thank you.

Host: Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. And that's all for today. I'm Scott Webb, and that was A Bone That's Fixed.