FAILED SPINE SURGERY / FAILED BACK SYNDROME
Spine surgery involves a complex procedure to retain the stability of the spine enabling movement without pain and discomfort. In some cases, the spine surgery may not produce expected result and the patient may still continue to experience the pain and inflammation even after the surgery. In this Failed back surgery syndrome (FBSS) the patient experiences severe pain and discomfort usually accompanied with stress and a long recovery period.
Various factors can lead to a failed spine surgery including failed spinal fusion, inaccurate diagnosis and surgical procedure, formation of scar tissues or new injuries in the spinal area all accounts to a failed spine surgery. The patient may also feel persistent pain, numbness, nerve compression or irritation, tingling and lack of mobility and even depression and anxiety due to the unsuccessful surgical procedure.
In such cases, the traditional surgical recovery treatment methods include pain medications, physical therapy, application of heat or ice and additional surgery. It can be tiresome for the patient to undergo repeated spine surgery and to cope up with the recovery and healing period repeatedly.
Alternative treatment methods for Failed back surgery syndrome at Beth Yehuwdah Arthritis Centre, Pullad & Daystar Clinic, Alappuzha:
One of the leading causes of disability is back pain, yet most of those who suffer from it do not know that the most likely cause of the problem is spinal instability! Degenerating spine often shows bone growth as the bone is formed from an attempt by the body to stabilize the spine. Spine Fusion surgery accelerates that type of stabilization. Spine Surgery with posterior instrumentation provides Rigid fixation of Spinal components thereby transferring most of the flexion extension movement to the facet joints above and below the level of fixation, which may increase degenerative stresses on the facet joints above and below the site of rigid spine fixation, which in turn may lead to severe pain long after surgery.
Regenerative treatments like PRP Prolotherapy and Dextrose Prolotherapy work in a totally different way. They attempt to stabilize the spine by strengthening the often forgotten and underappreciated spinal ligaments and muscle attachments. These techniques help stabilize the spine in a dynamic way, which can prove to be helpful in treating patients with failed back syndrome.
The stable spine during movement behaves like a see saw with its fulcrum at the facet joint. The disc in front is balanced by ligaments and muscles at the back. If there is damage to the ligaments/muscles behind the facet joint in the form of strain, more weight is transferred to the disc region in the front which may lead to disc prolapse. In Dr John’s experience Platelet Rich Plasma Prolotherapy and Dextrose Prolotherapy offer the best results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles at the back of the facet joint, thereby relieving stress in front of the facet joint namely the disc region. This is the same reason; it can be used to treat patients with Failed Back Surgery Syndrome.
Symptoms caused by Spinal Instability at single or multiple levels
Chronic Conditions caused by Spinal Instability: Radiculopathy, Spinal Canal Stenosis, Degenerative disc disease, Herniated disc, Numbness/ Weakness in upper limb & Cervical Spondylosis.
Many times a patient with neck or lower back pain; despite various treatments still has pain and now has been recommended spine surgery because “MRI shows something”. But is it in fact the disc prolapse on MRI always the cause of the patient’s pain? Medical researchers are asking, “Maybe we should look at the spinal ligaments?”
Patients who are in severe back pain usually bring an MRI/ X-ray and/or scan that may show an inaccurate picture of what is causing their pain. In a landmark study by Boden et al in the Journal of Bone and Joint Surgery (Am) 1990, which has been quoted by nearly 2700 other articles Dr Boden does MRI scans of the Lower Back for people who have no lower back pain, sciatica or neural claudication in lower limbs. He gets neuro-radiologists to interpret the MRI without them being told the history and examination findings. He found that 57% of apparently “normal” people above the age of 60 years without any backache or nerve symptoms in legs had “abnormal” MRI changes with 36% having Disc prolapse and 21% having Spinal Canal Stenosis. If 57% of apparently normal people have abnormal Spine MRI, how can we be sure that when a patient presents with back pain, that his pain is actually related to the bulging disc, when that disc bulge could certainly be asymptomatic. The MRI cannot show muscle spasms from a simple cervical/ lumbar strain which can cause excruciating pain. Neither can it detect early microstructural damage at the ligament bone junctions/ enthesitis nor can it detect nerve sheath CCPs (chronic constricting points) along the course of various nerves. Conversely, a herniated disc may be seen on MRI which may be completely painless. Yet that herniated disc will send the patient to surgery. Dr Tejaz John has observed in his clinical practice that at times patients may bring MRI showing disc prolapse towards one side whereas the symptoms are experienced on the opposite side.
Here is a statement from the medical journal Childs Nerv Syst. 2015:“As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.” Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic neck pain patient may have history of trauma or overuse to the neck that result in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent cervical instability.
Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic neck/ lower back pain patient may have history of trauma or overuse to the spine that result in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent spinal instability.
1) PRP Prolotherapy for Failed Spine Surgery/ Failed Back Syndrome Platelet-Rich Plasma Therapy (PRP) has been found to be effective in treating degenerative disc disease by medical researchers by dealing with the problem of spinal ligament instability. The sooner the spinal ligament instability as well as the degeneration is addressed, the better the results in patient satisfaction. In fact, abnormal stress on the spinal ligaments could be an important cause for most pain in degenerative disc disease.PRP is an effective means of alleviating neck and lower back pain because it eliminates pain by stimulating the local immune response to heal the underlying tissues and may not only help avoid surgery in cases of spinal ligament instability but can be used to treat patients with Failed Back Surgery Syndrome.
PRP prolotherapy is a combination treatment where PRP as well as Dextrose Prolotherapy is administered at the same time in the neck or back region. This treatment may help a patient who does not want revision spine surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.
How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:
Platelet-Derived Growth Factor (PDGF)
Attracts cells of the immune system to the site and stimulates their proliferation. Also shown to assist in healing of ligaments and tendons.
Transforming Growth Factor-ÃŸ (TGF-ÃŸ)
Similar affects as PDGF. It is Secreted by all major cell types involved in healing.
Vascular Endothelial Growth Factor (VEGF)
Helps in formation of new blood vessel, thereby increasing vascularity in injured areas.
Fibroblast Growth Factor (FGF)
Promotes the growth of the cells involved in collagen and cartilage formation.
Table 1: Various biological growth factors released by PRP when activated
PRP injection delivers a high concentration of autologous (patient’s own) platelets to the joints and soft tissues in the neck/ lower back. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the area using PRP injection stimulates the healing process and faster recovery from the musculoskeletal condition.
Dextrose Prolotherapy for Failed Spine Surgery/ Failed Back Syndrome
Neck and Lower back pain is one of the leading causes of disability, yet most of the people suffering from it do not know that Spinal Instability is most likely the real cause of the problem! We see, most patients take pain tablets and muscle relaxers to cover the pain, which only masks further degeneration and leads to an endless “pain management” cycle. This is like treating the symptoms versus correcting underlying spinal instability. Comprehensive Dextrose Prolotherapy can break this cycle by assisting the regeneration of weakened and stretched-out soft tissue structures of the spine, alleviating pain and instability. Using Prolotherapy, these conditions can be treated properly and safely to give a more desirable symptomatic outcome.
Dextrose Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. Prolotherapy is an effective non surgical treatment method used successfully in spinal instability and other spine conditions. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in and around the neck region. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles in chronic cervical Spondylosis.
We treat patients who have been diagnosed with bulging discs, degenerative disc disease, spondylolisthesis, failed back surgery syndrome, sciatica, and more. Using Prolotherapy, these conditions can be treated safely to give a more desirable pain-relief outcome
Patient Benefits of PRP Prolotherapy and Prolotherapy:
At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of minimally invasive treatment options for patients suffering from various spinal disorder conditions. To know more about Failed Spine Surgery Treatment plans and cost, book an appointment now.Authored by Dr TEJAZ KOSHY JOHN
MBBS, MS Ortho (Christian Medical College, Ludhiana), Joint Replacement Fellowship (HOSMAT Hospital, Bangalore), Orthopaedic Trauma Fellowship (Hebrew University Hospital, Jerusalem, Israel)Read More