After discussing lower-back pain assessments last blog, it’s natural to turn our attention to Failed Back Surgery Syndrome. This includes patients who experience lower-back pain for months to years, receive typical treatments but still suffers from chronic back pain. The best way to illustrate this is through example.
Failed Back Surgery Syndrome
“Joe” is a 35-year-old male, working a sedentary job. He exercises three times a week, including, sports, weight-lifting and yoga. Like many, Joe can’t recall any specific low back injury. He experiences “catching” lower-back pains when getting out of bed. Stretching tends to alleviate stiffness and bring his pain rate to a 3-4 out of 10. Luckily, it decreases as he moves. However, he again develops a deep muscular pain in his lower back when sitting at work. He is also developing an intermittent radiating pain down the right hip into the bottom of the right gluteal muscle.
Joe tries over-the-counter pain medication. He stretches more, but his hamstring and hip flexor muscles are getting tighter, while his abdominal and gluteal muscles, despite crunches, weaken. He feels better after a massage or acupuncture (both lying on his stomach), but sometimes the pain returns just getting off the table.
He visits a chiropractor for six weeks, receiving mid- and lower-back adjustments, as well as stretching on the flexion-traction table. The chiropractor orders x-rays and the L4/L5 and L5/S1 discs shows moderate degenerative changes. The diagnoses changes to chronic low back pain with degenerative disc disease. He may possibly have a bulging or herniated disc, but that cannot be determined by x-ray.
Joe already includes many of the chiropractor prescribed lower-back exercises and stretches in his routine. Frustrated, he sees to his primary medical doctor who prescribes muscle relaxants, stronger pain killers and anti-inflammatory medication. Joe doesn’t like taking medication, but they help him sleep and take the edge off the pain. He reduces his weight training and increases core exercises and stretches.
The pain is a 7/10 and the radiating pain is now down to his right knee. His base line pain stays consistently at 4-5/10. He stops playing sports due to pain and reluctantly migrates to stronger (opioid) pain medication and epidural injections. He stops chiropractic care and sees a physical therapist to strengthen his lower back and hamstrings.
Joe is depressed and referred to a psychologist for cognitive behavioral therapy to help identify behavioral changes like exercising again and meeting with friends.
An MRI finds degenerative disc disease, general disc desiccation (drying out) at several spinal levels, 50 percent loss of disc height at L5/S1 and 25 percent loss at L4/L5, with a 3 mm bulge at L4/L5 and 5 mm bulge at L5/S1 with decreased IVF size and mild contact of the L5/S1 nerve root from the bulging disc. No frank disk herniation is noted. Several other spinal levels have annular fiber tears, but no disc displacement. What does this mean? Joe’s low back spine shows degeneration. His last two discs are bulging, with his lowest pressing on the nerve root, causing the sciatic pain. Joe’s pain is very real.
Joe resists an orthopedic referral at first, but slowly warms up to the idea since he is not improving. The spine surgeon sends Joe to a different physical therapist for 4-6 months. If that doesn’t work, they’ll revisit the surgical option again.
Joe is not any better. He researches spine surgery outcomes, and while not impressed with the failure rate, he feels out of options. The surgery is a minimally invasive micro discectomy, only removing the bulging disc material. The surgery goes well. Joe is instructed not to bend, lift, or rotate for 4-6 months. He uses a back brace for additional stability and starts a walking program, working up to 30 minutes, while incorporating lower-back stretches. This pain is better. However, he is still on pain medication.
Eight Months Post-Op
Joe feels much better – a 2/10 pain – and returns to exercising, but without Olympic lifts. He continues yoga, prescribed stretches and exercises. During the next 12 months, his lower-back pain returns, and a L5/S1 lumbar discectomy with spine fusion is discussed. Joe regresses and a new MRI shows a herniated L5/S1 disc pressing on the spinal cord.
Avoiding the Path
Joe’s now a Failed Back Surgery Syndrome statistic, defined as a lower-back pain patient not relieved or worsened by back surgery. Unfortunately, this happens all too often, with a minimum failure rate of one in five lower-back surgeries!
Discogenic pain, lower-back pain, sciatica and mechanical lower-back pain often start with poor spinal mechanics learned early and carried into adult exercise. These aberrant spinal movements cause lumbar disc damage, which often present as muscle symptoms. Coupled with ongoing, high-risk and damage-inducing lower-back exercises and stretches (the internet is full of them), poor yoga form or incorrect seating posture, the disc condition worsens. Prescribed exercises and stretches target lumbar muscles at the expense of lumbar discs. These activities cause further disc damage and pain, so the patient doubles down on these deleterious movements. The condition worsens and the patient ends up in surgery, bringing temporary relief due to limited spinal movement. As the patient improves and returns to their old movement patterns the disc damage starts all over again, resulting in Failed Back Surgery Syndrome.
Doctors and therapist don’t always explore movements, loads and postures that aggravate the spine. Instead, imaging and pain level determine if surgery is required. Few teach patients spine-sparing movements, what movements to avoid or exercises that stabilize the spine without aggravating the discs. Patients often receive exercises with lots of spine movement (lumbar rotation, bending forward or backwards), destabilize the spine, causing annular tears in the discs and eventually disc failure.
Failed Back Surgery Syndrome is less a physical condition and more a result of incomplete diagnostic assessments. Isn’t it time to break the cycle? Let’s find the true source of your pain before proposing solutions. Contact Dr. Kai Tiltmann at Financial District Chiropractic for further information.