David S. Klein, M.D.

Failed Back Syndrome

Next to headache, more time is lost from work due to low back pain than from any other cause. With increasing frequency, patients are undergoing spinal surgery for pain alone, that is, pain in the absence of bladder/bowel dysfunction, muscular atrophy and numbness.

This stems from the prevalence of imaging centers that are readily available to perform MRI's, CAT scans, and such. It should be better recognized that the mere presence of an 'abnormality' on image does not imply causality.

A 'structural' abnormality may not be abnormal at all.

1. Imagine yourself sitting in a nearby shopping mall.
2. Approximately 1/3 of all persons walking about the mall will have a 'structural abnormality' on MRI.
3. These abnormalities may be labeled as "bulging disc" "herniated disc," or "degenerated disc."
4. These persons are functioning normally, without meaningful impairment.

Now imagine the same population simultaneously running into each other and pulling a muscle.

1. If all of these persons received MRI's, 1/3 would demonstrate the (pre-existing and asymptomatic) abnormal scan.
2. The muscle pull will then be misdiagnosed as a herniated disc, and too many of these end up having surgery.
3. It should then come as no surprise that only 1/3 of patients undergoing spinal surgery will experience pain relief. (NOTE: this means some decrease in pain, not elimination of pain.) 1/3 of patient undergoing spinal surgery will come out of it without any net change in symptoms.
4. 1/3 of patients undergoing spinal surgery will come out with worsened pain.
5. Many patients find themselves having undergone surgery without meaningful benefit.

Unfortunately, too many of these patients find themselves returning to the same surgery center for spinal surgery #2, surgery #3, and so forth.

The familiar progression is as follows:

1. Epidural Steroid Injections (ESI, LES) performed 3 times (the reason for the 3 or 4 injections is more a matter of tradition than of outcome measurement.
2. After the ESI's fail, as they most frequently do, the patient undergoes surgery #1, or lumbar discectomy/laminectomy. Failure of Surgery #1 leads to surgery #2, or repeat laminectomy/discectomy.
3. Failure of Surgery #2 leads to surgery #3, or spinal fusion.
4. Failure of Surgery #3 leads to surgery #4, or fusion with a cage, mesh, or some other fixation device.

The obvious problem is in patient selection. There are too many surgeons anxious to perform the surgery, and the criteria become softer and softer.

If the problem is that the 'abnormality' on MRI is not causing the pain, then an effort must be made to establish causality between the pain and the disc. To do this, the physician should obtain evidence that this is the case. Performing EMG, NCV, SSEP provides evidence of causality, if it exists. If a corraborating NCV does not demonstrate findings of lumbar/cervical radiculopathy, then surgery is unlikely to be successful.

David S. Klein, MD, FACA, FACPM, FACMIMS
Director, Pain Center of Orlando
www.suffernomore.com