HyperMED - Failed Back Surgical Syndrome
Onesti ST (Neurologist. 2004 Sep;10(5):259-64) stated that ‘Failed Back Syndrome (FBS) is a well-recognized complication of surgery of the lumbar spine. It can result in chronic pain and disability, often with disastrous emotional and financial consequences to the patient. Many patients have traditionally been classified as ‘spinal cripples’ and are consigned to a life of long-term narcotic treatment with little chance of recovery. The issue of chronic pain associated with failed spinal surgery was reported as far back as in 1994. The publication; Spine featured an article: Outcome of lumbar fusion in Washington State workers' compensation (Franklin 1994). Franklins et al. covered a large, population-based cohort of workers in the Washington State workers' compensation system who received lumbar fusion between August 1, 1986 and July 31, 1987 to determine work disability status, reoperation rate, and patient satisfaction. Most patients reported that back pain (67.7%) was worse and overall quality of life (55.8%) was no better or worse than before surgery. Conclusion: Outcome of lumbar fusion performed on injured workers was worse than reported in published case series. Prospective studies should be conducted to determine the biologic indications that might lead to improved outcomes in this disabled population.
Case Study : Mrs. RB age 49 - Post operative spinal complications The following is a direct testimonial by one of our patients, Mrs. RB aged 49 who suffered post-operative spinal complications.
In 1991, I was severely injured in an industrial accident whilst performing my normal employment duties. I was suddenly thrown into a solid wall by a large industrial floor polisher when it malfunctioned. As a result of this injury I have suffered constant pain and ongoing disability to the left side of my body including back and leg, and neck and arm. Between 1991 and 1994, I had numerous hospital casualty admissions, and on many occasions admitted for several days at a time for attempted pain relief. I have consulted numerous different specialist doctors and therapist with very little relief from pain regardless of the different medications, injections and treatments recommended. During February 1994 I began to lose feeling from my waist down. My specialist doctor admitted me to hospital for additional tests and within a matter of hours I was recommended spinal surgery for a ‘very bad disc compressing my spinal cord’. By this time the pain in my lower back had intensified dramatically and coupled with the fact that I had lost feeling from the waist down, I did not have any alternatives other than to go ahead with the spinal surgery. The surgeon assured me, that my pain would decrease and the loss of feeling would return with the procedure. For the next 8-months, I continued with strong pain medication, received extensive physiotherapy and hydrotherapy. I continued to be examined and reviewed by numerous insurance doctors. By this stage I was having nothing but problems with the insurance company. Unfortunately the pain did not settle but in fact my condition continued to deteriorate with me feeling extremely unstable in my lower back. I was devastated. I had been told that the operation would fix my back, instead I was worse. I became very depressed and emotional eventually requiring therapy with a psychologist and psychiatrist. I continued with these appointments for the next three and half years. Lucky for me, my treating doctor and therapists were very supportive of me, otherwise I don’t think I could have gone on. No matter what I did, who I saw, the pain in my back and leg and the pains in my neck were getting progressively worse. I was living with constant pain, I was severely restricted with any form of movement or activity, I used crutches for support and I was literally living on pain control medication. I was extremely depressed. My local treating doctor was and continues to be very supportive of me and I know that he has tried to recommend anything and everything he believes would be appropriate in an attempt to relieve my terrible pains. Under his direction I was receiving physiotherapy several times per week, massage twice a week, hydrotherapy daily. Medication included Panadol 2 every 4 hours, Panadeine Forte 2 every 4 hours, Zantac 2 every time before other medication, Zoloft 2-3 per day, Valium in various dosage 4-6 times per day, Endone several per day as required, Voltaren 2-3 several times per day, Aropax daily, Feldene and Aspirins throughout the day and many more drugs that I cannot recall. When I look back I know that my medication schedule was out of control. The trouble with chronic pain is that you become more and more addicted to the effects of the medication and when you are suffering terrible and relentless pain any form of relief is a blessing. I also had to wear a specially designed surgical back and orthotic leg support because I did not have the full feeling or control of my leg. I moved around most of the time with the aid of crutches, sometimes on a good day I may have got away with the use of one walking cane. When I was assessed during 1996 the specialist insurance doctor said I had suffered ‘permanent and irreversible damage’ to my spine. I was devastated and became totally depressed. Everytime I saw some form of back treatment, new drug or potential cure either on television or the newspapers, I would try and give it a go. Unfortunately, I never found any form of treatment or medication that seemed to fix the problem. In April 1997, I accidentally found the Spinal Rehabilitation Group. I did not even know what Hyperbaric Medicine was or what a chamber even looked like. As a matter of fact if I knew that somebody was going to put me inside a sealed chamber, regardless of the windows, I would have definitely said no and I would not have attended. But I was desperate. Dr Hooper examined my spine, requested new X rays and MRIs of my lower back and neck regions and took my case on a trial basis. I commenced HBOT and received physical therapy daily. I was so scared that during the initial weeks I took several Valium prior to going into the chamber to help me to relax me enough because I suffer terrible anxiety. As well as the chamber, I received other forms of treatment including electrical acupuncture, cupping and supportive chiropractic and physiotherapy. I was also recommend vitamins and received various injections. After 2-months of HBOT I was actually feeling quite well, I still had pain but I was completely surprised as to how well I was coping, not requiring anywhere near the same quantity of medication as before. My GP was also amazed at my quick response to this new form of therapy. He told me on several occasions that he had never heard of hyperbaric therapy for spinal problems other than it being used for the ‘bends’ as a result of diving injuries. He was supportive but I think he was still sceptical. Anyway, I continued to improve so he recommended that he begin to slowly reduce the amount of medication that he had been prescribing. I found it very difficult to withdraw from my medication; I suffered many episodes of terrible panic attacks. When I suffered these attacks additional treatment I received from Spinal Rehab Group helped me overcome these episodes which previously I would have been in a terrible state for many days on end. After 3-months of treatments, I stopped using the walking stick and I no longer needed the back brace every day. I have been unable to travel on public transport for the past 7-years because of my pain and anxiety attacks, I was totally dependent upon my husband to drive me wherever I had to attend. I am now able to travel more independently, I catch the bus, the train and I walk which has been a tremendous boost to my self-esteem, and relief to my husband. I have now had the best past 12-months since I first injured my back, I no longer require the same amount of medication and able to cope with the pain which is now considerably less. The episodes of pain and the frequency of attacks are significantly less and with the benefits of HBOT and treatment I seem to bounce back extremely quickly. I have now been enrolled in several courses at a higher education adult learning over the past year, which has been an absolute blessing. I am more confident, I’ve lost weight, have more energy, made many new friends and my general lifestyle and social activities have increased dramatically. I would like to thank Dr Hooper and his team for the special way they treat me and their patients and I thank God for a second chance. Lots of love Roze B”.
Almost everyone has a friend or relative who has suffered a ‘bad back’ or has had spinal surgery. Next time you are at your favourite restaurant, carefully observe the movement of the patrons. Before the night is over you will see most of the patrons squirming and shifting from side to side, invariably because of back-related problems. Most patients referred for assessment, which have had surgery; state that they have never been ‘quite the same’. In fact, even during the early 1990’s the American Academy of Orthopaedic Surgeons, reported in excess of 250,000 laminectomies performed each year (Spine Care San Francisco 1990). The Spine Care Medical Group states that in fact '90% of surgical procedures can be avoided’. ‘Effective non-surgical treatment programs do exist, however it is not uncommon that patients influenced by their doctor request surgery because Medicare and insurance companies will not pay for conservative care’ (Kirkaldy Willis 1995). Incredibly, government restrictions and ill-conceived health care cover programs are actually guilty of promoting unnecessary and potentially hazardous surgery. 20-30% of these operations are reported to be unsuccessful, with significant numbers complaining of additional recurrent complications and many requiring further complex surgical procedures. These figures seem to vary considerably depending upon which ‘authority’ you read (Waddell 1986). 'Disc surgery has survived the test of time for over half a century because at least 70-80% of carefully selected patients obtained relief. Recent reviews indicate that surgical success only applies to approximately 1% of the patients with complex low back disorders. The continuing clinical emphasis is upon the remaining 99% of patients with ongoing back pain for whom the problem has deteriorated and become progressively worse' (Waddell 1986). Review of recent hospital admissions at the Johns Hopkins Pain Clinic : Total admissions: 1,541, of which 1,032 (66.9%) were due to chronic spinal pain. 826 (80%) of these patients suffered chronic pain with a history of multiple surgical back procedures. 52 (.05%) were suffering chronic pain with no history of previous surgery. 'Often the decisions to undertake surgery are too frequently based upon the duration and severity of the patient’s pain and disability, including the patient’s ability to cope, levels of distress and illness behaviour and the fact that conservative therapy has failed to offer significant relief' (Waddell 1986). The outcome of surgery is also dependent upon the accuracy of diagnosis. Significant numbers of patients are still undergoing extensive and complex surgical procedures without MRI (Magnetic Resonance Imaging) investigations. Invasive discograms traumatise the disc with needle insertion and contrast filling material injection. Myelograms invade the central spinal canal, and in certain patients results in post procedural complications. Many patients can avoid or minimise post surgical complications or chronic recurrent back problems with early use of simple and sophisticated MRI investigations. 'Broad based spinal fusion and discectomy results with a significantly higher incidence for poor prognostic outcomes. Treatment emphasis of the long term incapacitated patient should be directed towards increased physical activity which will promote bone and muscle strength as well as improve disc and cartilage nutrition increasing systemic endorphin levels reducing sensitivity to pain' (Waddell 1986).
Hyperbaric Medicine in fact fulfils these recommendations.
Before HBOT After HBOT
This is a recent case; Mr. SM has suffered chronic back and leg pain for years. He is a builder and spent most of his working life involved with heavy lifting. He has consulted virtually every form of therapy over the years ranging from massage, chiropractic, physiotherapy, and naturopathy; received ongoing medical supervision taking anti-inflammatory and muscle relaxants. MRIs over a 2-years period; revealed continued structural instability and progressive neurological symptoms and eventually after increasing episodes of acute and debilitating pain he was referred to several surgeons and orthopedic specialists who all recommended discectomy and spinal fusion. As a last attempt to avoid surgery he decided to attend Hypermed (Melbourne Hyperbaric and the Spinal Rehabilitation Group) for intensive HBOT combined with appropriate physical therapy including direct electrical stimulated acupuncture. After 3-weeks of intensive HBOT a re-take of his MRI reveals considerable reduction of the sequestrated disc and reduction of both the compressive effects on both the lower cord and exiting nerve roots. His condition remains stable!
It is easy to see that the problems associated with chronic back problems and 'failed back surgery' are enormous. How can this happen? Are there really so many failed surgeries? Can failed surgery be avoided? Can failed surgery be corrected? Can it be avoided completely? Once a patient receives a diagnosis of 'failed back surgery', they are frequently labeled as 'hopeless' and ostracized not only by the medical community but also by their fellow workers, employers, friends and even family members. Many lose their sense of identity, direction, the ability to cope and the drive to go on. Most failed back operations can be avoided, and are usually caused by a very well meaning surgeon operating on the wrong patient for the wrong indication. Removal of the disc and lamina may assist the patient's leg pain in the short term, but frequently complicates the long-term condition of the patient, since it precipitates further narrowing and hastens the overall degenerative process. Laminectomy and or discectomy is reported to be 90% effective in relieving pain radiating below the knee in patients disabled by severe pain. However, the big problem is to then determine what additional instability is imposed by the surgeon's knife because of removing vital structures in an attempt to alleviate the immediate radiating pain and the fact that the region is rendered vulnerable to the potential of opportunistic infection. Microscopic discectomy for the removal of extruded disc fragments has also been reported to be a successful procedure. However, this procedure can also result in incomplete extraction of the fragment material or lead to recurrent disc herniation. Unfortunately, the incidence of post surgical scarring, infection, accelerated discogenic complications and spinal canal compromise is high.
Waguespack A, Schofferman J, Slosar P, Reynolds J. SpineCare Medical Group, San Francisco Spine Institute, Daly City, California, USA. Pain Med. 2002 Mar;3(1):18-22 BACKGROUND: Patients who do not improve after lumbar surgery may be given the nonspecific label of failed back surgery syndrome (FBSS). Since 1981, there has not been a quantitative assessment of the etiologies of FBSS despite major improvements in surgical techniques and diagnostic testing. PURPOSE: To define the causes of FBSS seen in a referral-based spine center. STUDY DESIGN AND METHODS: Retrospective review of 181 consecutive charts of patients seen at a single spine center because of continued pain after lumbar surgery performed elsewhere. Evaluation was individualized based on history and physical examination and included x-rays, CT scans, MRI, selective nerve root injections, discography, and psychiatric evaluation. PATIENT SAMPLE: There were 101 men and 80 women; mean age was 47 years. There were 118 patients with one prior surgery, 52 with two, 6 with three, and 5 with four. Mean interval from the last prior surgery to the first clinic visit was 33 months. RESULTS: A predominant diagnosis could be established in 170 of 181 (94%) patients, and included foraminal stenosis (29%), painful disc(s) (17%), pseudarthrosis (14%), neuropathic pain (9%), instability (5%), and psychological problems (3%). CONCLUSION: We were able to establish a predominant diagnosis in 94% of our patients. Foraminal stenosis remains the leading cause of FBSS, but painful discs are also common. Recurrent disc herniation is seen less often than in the past, and there is increased recognition of neuropathic pain. Knowledge of the potential causes of FBSS leads to a more efficient and cost-effective evaluation of these patients.
It is easy to see that the problems associated with chronic back problems and ‘failed back surgery’ are enormous. How can this happen? Are there really so many failed surgeries? Can failed surgery be avoided? Can failed surgery be corrected? Can it be avoided completely? Once a patient receives a diagnosis of ‘failed back surgery’, they are frequently labelled as ‘hopeless’ and ostracized not only by the medical community but also by their fellow workers, employers, friends and even family members. Many lose their sense of identity, direction, the ability to cope and the drive to go on. Most failed back operations can be avoided, and are usually caused by a very well meaning surgeon operating on the wrong patient for the wrong indication. Removal of the disc and lamina may assist the patient’s leg pain in the short term, but frequently complicates the long-term condition of the patient, since it precipitates further narrowing and hastens the overall degenerative process. Laminectomy and or discectomy is reported to be 90% effective in relieving pain radiating below the knee in patients disabled by severe pain. However, the big problem is to then determine what additional instability is imposed by the surgeon’s knife because of removing vital structures in an attempt to alleviate the immediate radiating pain and the fact that the region is rendered vulnerable to the potential of opportunistic infection. Microscopic discectomy for the removal of extruded disc fragments has also been reported to be a successful procedure. However, this procedure can also result in incomplete extraction of the fragment material or lead to recurrent disc herniation. Unfortunately, the incidence of post surgical scarring, infection, accelerated discogenic complications and spinal canal compromise is high. Patients having undergone such procedures and now experiencing ongoing and recurrent pain require extensive diagnostic investigation, including gadolinium enhanced MRI scans, radioisotope bone scans and in many cases myelo-disco-CT scans for further diagnosis. Further surgery is often extremely complex, with significant ongoing disability. Surgical ‘block’ spinal stabilisation for spinal cord problems often precipitates a degenerative cascade of spinal and related structures with a high incidence of secondary segmental disc herniation. It would take an entire volume to discuss this incredibly complicated subject. Failed back surgery is a fact. You cannot avoid the issue of back problems by just getting a ‘crack’, massage and stretch or by going to the gym. Many treatments and exercise programs recommended with good intentions often contribute to the underlying structural condition because correct investigation was not initially conducted. Our recommendations are that any person suffering ongoing or recurrent back and related problems be reviewed by an appropriate doctor and have current investigations, including functional loading X-rays performed of the area. If the condition persists, MRI investigation may be required to accurately determine the underlying problem and then an appropriate treatment strategy will need to be implemented. If the patient also suffers additional symptoms that appear to be unrelated including chronic fatigue, migratory joint and musculoskeletal pains then investigation should include PCR DNA screen for opportunistic infection and co-factors.
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“My name is Roze and for the past three years I have been receiving Hyperbaric Oxygen Therapy and physical therapy at the Spinal Rehabilitation Group under the direction of Dr Malcolm Hooper.
