Joey Wahler (Host): It can make the second time a charm. So, we're discussing failed back surgery syndrome and revisional spine surgery. Our guest is Dr. Griffin Baum, a spine and neurosurgeon at Tallahassee Memorial Healthcare.

This is The Pulse at Tallahassee Memorial Healthcare. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Baum. Welcome.

Griffin Baum, MD: Hey, Joey. Thanks so much for having me.

Host: Oh, please, we really appreciate the time. And first, simply put, what exactly is failed back surgery syndrome, for those unfamiliar?

Griffin Baum, MD: Yeah. Failed back surgery syndrome is a very unfortunate diagnosis, and it relates to people who have had a previous back surgery, does not really matter what kind of back surgery it is, but most commonly, they're usually prior spinal fusion operations where a patient has gone greater than six months in surgery without the relief of their symptoms, and oftentimes a worsening of new symptoms as well as their original symptoms.

Host: And what would typically be a reason or two that someone would've had that first procedure?

Griffin Baum, MD: The most common causes for spinal operations in United States are either herniated discs or lumbar stenosis. And patients can also have alignment issues related to the spine or even nerve compression, which would require screws and rods and even fusion graft that's put in to try and recreate or optimize their spinal alignment.

 Unfortunately, it's not uncommon for either the fusion to fail, meaning that bone graft does not fill in appropriately or sometimes in the effort to improve the alignment, patient's alignment can actually be worsened, which can lead to new and worsening problems from their original.

Host: Gotcha. So having said that, how can revisional spine surgery address those issues? How would you say it most differs in approach from the primary spine surgery that will have already occurred?

Griffin Baum, MD: Well, I think the biggest difference between primary and revision spine surgeries is really the need for planning, and there's much more history that's required during the preoperative evaluation, and it's really difficult to understand not only what the patient's current symptoms are, but what the symptoms were originally and how the original surgery which was performed maybe tried, but unfortunately failed to address those issues. Because oftentimes with failed back surgery syndrome, we're not only fixing the prior issue, but also trying to resolve some of the newer problems that have resulted since that first surgery. So in many ways, it's almost like a two-for-one or three-for-one.

Host: Gotcha. So, there are further problems that may have occurred as a result of the first surgery not meeting its goals, right?

Griffin Baum, MD: Yeah, it's correct.

Host: So, how do you approach diagnosing failed back surgery syndrome in the first place? What diagnostic tools and imaging are most effective there?

Griffin Baum, MD: It's kind of funny because, in many ways, you don't really need any of that stuff to make the diagnosis. Because basically if you have a patient who's greater than six months out, miserable, and the surgery didn't make them better, but made them worse, it's pretty easy to give them that diagnosis.

And oftentimes, these patients come in with a plethora of imaging. So, they've already had x-rays, they've already had CT scans, they've already had MRIs. And in addition to that, they usually have already exhausted all of the other conservative therapies, things like physical therapy, occupational therapy, epidural steroid injections, chiropractic therapies, even acupuncture.

Host: And so, that was going to be my next question. I was going to ask you what non-surgical treatments might manage their situation short of having another surgery, but you just ran down the list and you say normally they've tried at least some, if not all of those things, by the time they get to you, right?

Griffin Baum, MD: Yeah. That's what makes it really difficult is, you know, oftentimes for the sort of run-of-the-mill degenerative spinal conditions that are related to arthritis, greater than 80% of those patients improve with those conservative-type therapies, things like physical therapy and injections. Unfortunately, these patients do not really ever improve. In fact, in many ways, over time, they can get worse and worse.

Host: How does a patient's initial surgery, their surgical history, influence your approach to the revisional surgery? What are some of the things you need to be aware of and you want to act upon to make the second time that charm that we alluded to earlier?

Griffin Baum, MD: So, there's a combination of factors that are very important. The first one is verifying what the symptoms were originally and trying to match that up with the surgery that was performed, because oftentimes there could be a technically perfect operation that was performed, but maybe done for the wrong reason.

 You have a patient who ended up having, we'll say, a fusion operation where you put in screws and rods, but it was done for something like lumbar stenosis where the screws and rods weren't necessary and maybe the decompression never occurred in the first place. And so, oftentimes, that could be the easiest case because you just do the right operation the second time and patients typically get better.

 Other times, which is generally the more complicated one, is when patients had the correct surgery and, for whatever reason, they didn't heal appropriately, they had a complication. Commonly, screws can pull out. The vertebra above and below where they've had a fusion can fracture or collapse. And really, that's when things become quite complicated because we're not only managing maybe the surgery that didn't go well, but now we're managing several other issues that, if left unaddressed, essentially guarantee another failure.

Host: I'm wondering in your experience when a second surgery is needed. As great as it sounds, being able to correct the problems from the first procedure, how often do patients become reluctant and say something along the lines of, "You mean I've got to go through something like this again?" Because I'm sure they feel the first time was a very big deal, right?

Griffin Baum, MD: Interestingly enough, the majority of these patients are pretty clear that something's wrong. And there are definitely those patients who remove themselves from the medical system. So basically, they've had such level of dissatisfaction with their previous care and maybe the answers that they've gotten from other physicians and practitioners, they sort of just-- I don't want to say give up-- but they just disconnect from everything and say, "Oh, I'm going to make do." More often than not, the pain gets to be so severe that really they are the opposite of reluctant. They're actually almost begging for something to be done.

And honestly, that's what makes treating these patients all the more difficult because there are circumstances where there's not a good surgical solution, or the surgical solution is so large, the recovery is so great, and the medical risks are so high that, even though these patients are absolutely miserable and debilitated, surgery's really not an option. And those are the patients they end up spending the most time with in the office. The ones who just have screws out of place and fractures and stuff that's easy to fix, those patients, it's quite straightforward. Say, yeah, we can fix this. It's those other patients that's just really tricky and really tough from a mental standpoint.

Host: Interesting. So on the one hand, they are usually willing participants. On the other, sometimes you're not going to get optimal results, as you said. You mentioned the potential for risk. What are the risks in this instance?

Griffin Baum, MD: Anything and everything that you could possibly imagine, there are the surgical risks, which are generally pretty well controlled with a good surgical plan. I mean, making sure that screws are in the right place. And we target the proper alignment through specialized cuts in the spine, making sure that all the nerves in the sack of nerves are decompressed. Those things are very straightforward.

The things that are more difficult to control are issues related to the heart and lungs, issues related to the kidneys, any sort of immunosuppression or nutritional, we'll say, weakness which would predispose them to an infection or a wound healing problem. And then, really, the biggest risk in my mind are mobility issues where patients go through these giant operations that typically carry a six to 12-month recovery. But if they never get up off the couch, if they never get up and start moving again, if they're never able to do the rehab, I don't want to say there's no point, but they never will fully realize the benefits that come from going through all that pain and suffering.

Host: And so, speaking of which, give people an idea, please, Doctor, of what that recovery time, that rehab is like.

Griffin Baum, MD: I would say, minimum, in the most basic circumstances, you're looking at a three to six-month recovery. Now, that's not three to six months on bedrest. That's not three to six months on pain medications. But typically, I define recovery as more good days than bad days and days that you forget that you had surgery.

And really, for the run-of-the-mill failed back surgery syndrome patient, they are very, very aware that they've had surgery and very aware that they've had multiple surgeries. But typically if you can take someone who has lived at an eight out of 10 pain level for years and say we cut that in half, and now they're at a four out of 10, maybe that means they can be more active for a couple more hours a day, or maybe they can be a little bit more mobile or maybe they can regain some level of independence. And the goal is always for independence, to be off of pain medications, and to really have the quality of life that you expect.

One of the other tough things is to recognize the fact that these are on par with other chronic medical illnesses. And I'll give you kind of a sobering fact, which is for patients who have developed a spinal deformity, which is some sort of alignment problem where they're either bent forward or bent to the side, those patients from a physical function standpoint, if we compare what are called patient-reported outcome scales, they are as disabled as someone who's undergone a heart and double lung transplant.

Host: Wow, that's certainly eyeopening indeed, huh?

Griffin Baum, MD: Yep.

Host: Couple of other things. How about recent advancements in surgical techniques and technology that have improved these outcomes you're discussing for revisional spine surgery?

Griffin Baum, MD: So, I think without question, the greatest improvement over the last five to 10 years is not a widget, it's not an implant, it's not a screw. It is really in surgical planning. And so, one of the things that I use or really rely on in the operating room is there is an AI-driven platform where we can actually upload patient's images. So usually, we use their x-rays, their CT scans, their MRIs. We enter some important factors like their height, their weight, their bone quality, obviously their age, their sex. And what we can do is that we can actually use those images. And we can simulate different surgical techniques. And so, we can see, okay, if we do a 30-degree osteotomy here, if we do multiple five-degree osteotomies here, if we put in an implant anteriorly here, we put in screws and rods here, what's our expected alignment?

And those alignment goals are targeted based on some really interesting research that's been done by some of my colleagues in spine surgery where we correlate their patient-reported outcomes, which are generally pain and physical function to what their alignment should be. And so, by trying to marry those two things and having a really good surgical plan going into the operating room. More often than not, we can get pretty darn close to those numbers that we're shooting for. And that's personally been the greatest improvement in my practice. I used to do that, you know, I would have Photoshop open and I'd have a paper open over here. And now, this happens automatically. So, it's a huge quality of life improvement for me and certainly a big improvement for patient outcomes after surgery.

Host: Yeah. AI making its presence felt more and more throughout the medical world, right, Doc?

Griffin Baum, MD: Yep, no question. It's definitely an important tool. A tool that obviously comes with risk. I think any new technology, we've got to understand how it works before we can really fully trust it. And I think keeping things in the appropriate context, not relying on it too much is pretty important.

Host: And then finally here, Doctor, in summary, after a successful revisional spine surgery, you mentioned a moment ago, the goal generally speaking is hopefully, at least in some cases, to at least cut in half the amount of pain or limitations that a patient had in terms of activities, in terms of functions of daily life, as they say. What are some of the things that patients optimally are able to get back to so that when they come back to you down the road after this procedure, they say, "I'm able to do X, Y, and Z once again, and I can't thank you enough"?

Griffin Baum, MD: Physical activity is definitely one. I think at the most basic level, walking, being able to walk around their house, being able to walk down to the end of their driveway and get their mail. Being able to walk around the block, walk around the supermarket, really as just a sort of basic first step. That's definitely one of them.

The second one that I hear a lot from patients is to be able to stand in the kitchen, be able to cook, be able to entertain for their family. I love to cook. It's one of my hobbies. And I think we are social creatures as human beings. And one of the most important social things that we share is sharing a meal and cooking. And so, for those people who have been traditionally the caretaker in the family and the chef and the cook to be able to do that again really can be transformative.

The third one that I hear people talk about all the time is travel. And if you think about it walking and mobility, you know, arguably one of the most important things is just being able to go through the trials and tribulations that come with, whether it's getting on an airplane or getting in a car or going on a cruise and being able to walk and being able to experience things outside of your neighborhood and outside of your house. I think these are the things that really bring richness to life and to be able to give that back to patients is incredibly gratifying. I love seeing pictures. I love hearing stories. And that's always the goal and the hope.

Host: It's great to hear. And it sounds like in a nutshell, it's all about giving people back their independence and their confidence, right?

Griffin Baum, MD: Yeah, without question. Just when you have, say your car, right? And your car is broken down and you've put it back together and you've gotten it repaired. But maybe you're a little bit nervous about driving to the other side of the town or maybe getting on the interstate. And now, in that analogy, replace the car with your body and you're not able to rely on making it to the other side of the house or maybe making it all the way through the supermarket without running into problems. And so, that confidence that you are resilient enough to make it through, yeah, that can be very powerful.

Host: I'm sure it is. Well, folks, we trust you are now more familiar with failed back surgery syndrome and revisional spine surgery as a result. Dr. Baum, great to hear about your experiences. Keep up all your great work and thanks so much again.

Griffin Baum, MD: My pleasure. Thanks again for having me.

Host: Absolutely. And for more information about complex spine surgery at TMH, please do visit tmh.org/complexspine.

If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. And thanks so much again for being part of The Pulse at Tallahassee Memorial Healthcare.